A compendium of managed care: past, present, and hints of the future--Part II

Unpaid Radiology Claims in New Jersey: Incidence and Financial Implications

OBJECTIVE

Nonpayment of claims by insurers may lead to major financial losses by physicians. These losses may far exceed the losses from late payment that we studied previously, although it is late payment that has been the primary focus of legislation enacted in 47 states. This article quantifies the loss to radiologists from nonpayment of claims submitted to payers on behalf of patients with insurance.

MATERIALS AND METHODS

We analyzed all claims (48,217) submitted in February, June, and October 2000 to six major payers by a common third-party billing company on behalf of 11 radiology practices in New Jersey. Claims were categorized as unpaid (unpaid > 170 days after submission), paid timely (within 40 days of submission, the criterion of the New Jersey Prompt-Pay Act, effective December 28, 1999), or paid late (40-170 days after submission). A detailed analysis of 5,638 claims from the practice of two of the authors was used to estimate a "clean claims" (claims without defect or need for substantiation) submission rate.

RESULTS

The revenue loss from unpaid claims was approximately $156,000, which was 28 times the loss of interest that should, according to law, have been paid on the delayed paid claims. Of the unpaid claims, the payers never disputed 68%, involving approximately $106,000.

CONCLUSION

The financial consequences of unpaid claims far exceed those associated with late payment, even omitting all unpaid claims that were disputed by payers. Legislation coupled with active enforcement should address this large problem of unpaid claims, which is many times larger than the already legislatively targeted problem of late payment.