But on a day-to-day basis in a physician's office, will an administrator be able to convince the payer to pay a claim without further question because the response took 42 days instead of less than 30? Possibly, Quadrino says.
"You may have to press it and tell your contact at the insurer to move it up the food chain and check with their counsel," he suggests. "It's not going to be something they accept the first time you say it, but if you insist that this is the law and they should confirm it with their own people, they should realize you're right. Then maybe the next time they'll know that they should just pay."
Bills related to automobile accidents may be easier to handle in this regard, Quadrino says. Aside from other regulations, state laws typically require auto insurers to pay claims within a certain time frame, usually 30 days. The case law is more developed in this area, so the insurers are well aware that they must pay claims past the deadline, he says. "The office manager can just call Allstate and say the claim is at 33 days, and they'll say, ‘Oops, sorry,' and send the check in full," he says. "The six- or nine-month odyssey of how the claim was coded, all of the back and forth, is skipped. They just pay the claim."
Health insurers are not at that point of acceptance yet, but Quadrino says more court decisions in his favor will keep pushing the industry in that direction. A California appeals court recently affirmed the requirement for payment after the deadline is missed.
"This doesn't have to involve a lawsuit," Quadrino notes. "You may need to involve a lawyer who understands these requirements, but a lot of times it can be worked out with a high-level discussion between the lawyer and the insurer's legal counsel."