August 14, 2019

America recently remembered an act of defiance that would forever change the course of world history.  It was 243 years ago—this past July 4—that a small group of colonists penned their intention to resist unto death the scourge of unrestrained tyranny.  Though they were small in number and resources, they determined to take on, and grapple with, the greatest military force on Earth.  Regardless of the cost, they would strike a blow for liberty.

Americans have always been willing to fight the good fight.  It’s part of the national DNA.  That remains true to this day.  We chafe under the yoke of injustice and rail against perceived unfairness.  A recent example of this “I’m mad as heck, and I’m not going to take it anymore” attitude was seen in one of our state capitols—where the people rose up and struck a blow for fairness.

Earlier this summer, the Illinois legislature—in a unanimous vote—passed a bill that may end up being “the shot heard round the world” when it comes to the fight against unfair payer denials.  For years, providers in the Land of Lincoln have decried the lack of cooperation on the part of some payers to release reimbursements on a timely basis.  However, delays were not the only problem experienced by facilities and clinicians.  Often, claims were denied outright for reasons that did not appear to square with the payers’ own policies.  For example, it was found that 26 percent of claims were denied on the first pass by the state’s Medicaid managed care organizations (MCOs).

It is difficult enough to work long hours, providing superior care, in often stressful circumstances.  Having to then fight tooth and nail with an insurer’s representative just to receive reasonable remuneration for the services you rendered is the height of injustice.  This kind of frustration has been felt by providers around the country—and in growing numbers. In Illinois, at least, someone is putting a stop to the increasing incidence of unfair delays and unjust denials.

Senate Bill (SB) 1321 requires Medicaid managed care plans to pay claims within 30 days or face a penalty.  Furthermore, the bill prohibits passing any increase in the MCOs’ administrative costs on to the consumer.  These payers are now suddenly incentivized to become highly proficient in the processing of claims.  Failing to be so will mean severe financial consequences.

The passing of SB 1321 heralds new hope in the fight against undue payment delays.  We have noted for some time now a rising tide of go-slow tactics being used by certain payers on a systematic basis.  The Illinois legislation has the potential of turning this trend around on a national level.  The larger medical community should consider the following in support of that assessment.

Big Outcomes Have Small Beginnings

Yes, SB 1321 is good news for the people of Illinois—and specifically for the providers and beneficiaries connected with Medicaid MCOs.  However, this is only one state and involves only one small segment of that state’s insurance base.  How could this provision possibly translate to greater relief beyond Illinois’ borders?  I’m sure no one thought at the time that a band hammering out a new sound in a Seattle garage would redefine rock music within a few years.  Ever hear of Nirvana?  No one thought two high school pals would go on to develop an operating system used in nearly 80 percent of computers today.  Does Microsoft ring a bell?

The fact is that state governments tend to sit up and take notice of what other states are doing to improve the efficient delivery of healthcare.  The Illinois legislation is exactly the kind of flashing neon sign that will get the other states’ attention and perhaps provide the impetus in other capitols to enact similar provisions.  It should be noted that Illinois is a major player on the national stage and home to America’s third largest city.  Legislatures in other states are assuredly aware of SB 1321, and some may follow suit.

The Proof is in the Popularity

The most startling fact about the legislation recently passed in Illinois is that it garnered 100 percent support in both chambers in Springfield.  This massive wave in bipartisan backing provides strong evidence that this is an idea whose time has come, and it may prove unstoppable when it comes up for consideration in other states.

To be sure, each state has its own distinctiveness as it concerns political proclivities and healthcare priorities.  However, unanimity by any state on this particular issue would suggest that the delay and denial tactics used by various payers across the country have stirred a wasp nest of resentment.  Medical societies and advocacy groups and state agencies have been looking for some kind of recourse, and they now have a model from which to fashion their own customized solutions.

Strike While the Iron is Hot

Now that Illinois has passed a provision to penalize undue delays in payment for a certain class of health claims, it is up you to encourage your advocacy groups to get on the bandwagon and support similar legislation in your state.  Health regulatory agencies or departments, state senators and state representatives should be sent articles concerning the recent Illinois action and encouraged to follow suit.

The solution will involve different parameters in each state.  The problematic payers may not be the same in Texas as they are in New York.  Perhaps the proposals should not be limited to only a certain class of carriers but rather across the board, as allowed by law.  The key is to act now while the momentum is moving in our direction.  Strike while the iron is hot.  Strike a blow for basic fairness.