It is not uncommon for an insurance company to deny a claim years after the physician performs a procedure and after the patient received the benefit of insurance coverage. In practice, the insurance company collects amounts it feels were overpaid to the doctor for a covered claim by making an adjustment to future payments. 

 

This insurance practice is unfair and is bad news for more than doctors. It's bad news for Mississippians. When the physician disagrees with the findings the insurer is allowed to deduct the claim from the balance owed the physician. The appeals process can be convoluted and interferes with patient care. This practice could result in patients being held responsible for the repayment to the physician.

 

Currently there is no limitation on retrospective claim denials for health insurance claims paid to physicians for services rendered. Situations have arisen in recent years where physicians have been asked to repay a claim paid in error, sometimes years after the date of the claim.

 

Once the insurance company "looks back" and denies a previously covered claim, then both the patient and the doctor are left "holding the bag." The doctor must find the patient for payment if the adjustment was valid while at the same time consider his or her rights to appeal an erroneous adjustment of the insurance company.

 

Outdated or erroneous "look back" adjustments can destroy relationships between physicians and insurers such that a physician will no longer accept certain insurance coverage. In that instance, patients are left without adequate access to physician care. Not all insurance companies operate in this manner. In fact, Blue Cross Blue Shield, the largest health insurer in Mississippi has endorsed this change in statute as a method to ensure good working relationships between physicians and health insurance providers. 

 

Mississippians deserve a fair claims process. Alabama, Arizona, Colorado, Georgia, Maine, Missouri, Virginia and West Virginia all have twelve month limitations on retrospective health insurance claim denials. District of Columbia, Maryland and Texas have six month limitations on retrospective claim denials. Nearly half of the states in the U.S. have some form of limitation on this practice.

 

MSMA believes that if twelve months is enough time to file a claim, then it is only fair that adjustments to claims be limited to twelve months as well.

 

Another insurance issue doctors will support this legislative session is the need for compulsory automobile insurance laws. Physicians of this state provide trauma care to the citizens when they need it most; however, doctors who participate in the trauma system receive about a quarter percent of the fee normally charged for trauma for insured patients.

 

The Mississippi Trauma Care Task Force Report of 2007 showed that Mississippi ranks third in the nation for unintentional injury deaths at 58.1 per 100,000 persons, most of which (58 percent) are the result of traffic accidents which are the leading cause of trauma in the state. Mississippi amended its compulsory automobile liability insurance law in 2001 that requires all drivers to maintain liability insurance and carry an insurance card in their vehicles at all times as proof of this insurance.

 

Currently, the minimum automobile liability requirements in Mississippi are $25,000 per person (limited to a single accident), $50,000 per accident for bodily injury and $25,000 per accident for property damage. These insurance amounts are not adequate to cover trauma care. Uncompensated trauma care costs exceed $90 million per year. Mississippi needs to increase these minimum amounts of liability. 

 

The compulsory insurance laws are insufficient to promote compliance. Some drivers either misrepresent themselves as having insurance by purchasing a policy in order to obtain the card and then abandon premiums or driving completely without insurance.

 

During the 2010 Regular Session MSMA will seek legislation to require an increase in penalties sufficient to ensure compliance with the laws and seek the creation of a database to cross match insurance policies with vehicle identification numbers to assist law enforcement officers with compliance. 

 

Strengthening the compulsory automobile insurance laws will provide all Mississippians with better access to the Mississippi trauma care system and improve the trauma system by lessening uninsured impact. MSMA hopes to move this legislation forward to better the trauma care system in Mississippi and in turn make Mississippi a safer place to live and drive.