Mid-Atlantic Health Law TOPICS

Health care providers understand that they should send their bills out within a certain time period from the date services are rendered, but what is that time period? Does it vary from payor to payor?

Unfortunately, there is no uniformity. However, the various billing deadlines applicable in Maryland for each payor category are set forth below.

A. Health Maintenance Organizations

Under Maryland law, an HMO must give a provider a minimum of 6 months from the date a covered service is rendered to submit a claim for reimbursement.

Maryland law further specifies that an HMO enrollee is not liable for, and a provider may not bill an HMO enrollee for, services covered under the patient's HMO contract (except for any copays and deductibles). This rule applies whether or not the provider is part of the patient's HMO panel.

Accordingly, a provider who is not paid because the provider fails to submit a bill to the HMO on time may not charge an HMO enrollee for services covered under the enrollee's insurance contract. The HMO's refusal to pay the bill due to missed billing deadlines does not render the service in question "not covered."

Providers should note that their HMO provider agreements may specify a time-frame other than the required minimum. In such cases, a longer period will be available for submitting bills. Also, providers should be aware of "point-of-service" HMO plans. In such cases, the patient will be responsible for the difference between the "non-panel" reimbursement and the provider's charge, whether or not the HMO is billed on time.

B. Commercial Indemnity Insurers

Maryland law also provides that an insurer or non-profit health insurance plan (Blue Cross/Blue Shield) must give a provider a minimum of 6 months from the date a covered service is rendered to submit a claim for reimbursement.

Absent a provider agreement to the contrary, a provider is not prohibited by law from billing a patient for services which the patient's health insurance covers. Therefore, a provider may generally pursue payment from a patient covered by health insurance, even if the insurer will not pay the claim due to the expiration of the billing time limit. It is possible, however, for the patient to defend such a claim by arguing that the provider agreed to bill the insurance company on time on the patient's behalf, but failed to do so.

As with HMOs, a provider panel agreement may provide a longer time period than the required minimum for the submission of claims, but the agreement arguably should not shorten the time-frame.

C. Maryland Medical Assistance

With two exceptions, the Maryland Medical Assistance program will not reimburse a provider for services provided more than 9 months prior to the receipt of the invoice by the program. The exceptions are:

1.If the patient receives eligibility retroactively, subsequent to the service date, the provider may bill within 9 months after the date that eligibility is determined; and

2.If the patient is also Medicare-eligible, the provider may bill Medicaid within 120 days of the Medicare remittance date.

The Maryland Medical Assistance program's regulations specifically prohibit a provider from billing the patient if the program payment is unavailable due to late billing.

D. Medicare

Pursuant to federal regulation, a bill may be provided to the Medicare program up to the last day of the calendar year following the year in which the service was rendered to a Medicare beneficiary. For services rendered in the last three months of a calendar year, the time-frame is extended to the last day of the second following calendar year.

The Medicare Carrier's Manual states that, if a physician accepts assignment, and fails to bill Medicare within the allowable time-frame, the physician cannot then bill the Medicare enrollee. (Although the physician is still allowed to collect appropriate co-payments or deductibles).

If the physician does not accept assignment, it is the enrollee's responsibility to seek reimbursement. However, if the provider fails to bill the patient within the applicable time limit, the patient might refuse to pay the reimbursable portion of the bill by arguing that the provider should have known the patient intended to seek reimbursement.

E. Self-Insured Employer-Sponsored Health Plans

There are no legal limitations or safeguards regarding the submission of invoices to self-insured employer sponsored health plans. Each plan sets its own time limit, and they are frequently set at 90 days.

There are also no protections for patients with employer self-insured plans. In other words, the debt remains the patient's, even if the provider is not permitted to bill the plan. If the provider knows about the self-insured plan's deadline, then a patient might be able to defend a request for full payment by the provider on the theory that the provider agreed to bill the self-insured plan on time.

F. Conclusion Given the array of third-party payors and the different rules applicable to each, providers need to give clear advice to their billing personnel. Failure to do so risks rejection of a provider's bills, followed in many cases by the inability to seek payment directly from the patient. For more information, please contact: Barry F. Rosen