Doctors complain insurer pays late

State medical society may sue CareFirst over millions owed on Shore

June 29, 1999|By M. William Salganik | M. William Salganik,SUN STAFF

Doctors and hospitals routinely complain about slower payments from insurers, but complaints have grown more intense on the Eastern Shore, where, the state medical society says, CareFirst BlueCross BlueShield is behind on paying millions of dollars in Medicare claims.

"The doctor-patient relationship is being abused by insurance companies like CareFirst, whose own administrative malfunction puts doctors in the position of either rendering services at their own expense or denying services," said Dr. Wayne Spiggle, president of the Medical and Chirurgical Faculty of Maryland, in a letter to CareFirst.

The society, also known as MedChi, said it will consider legal action if the Shore problems are not resolved quickly.

The insurer conceded that it has developed a claims backlog, but said it hopes to catch up within four weeks. CareFirst said it has paid $5.1 million, or 81 percent, of Shore claims since November, when the problems began.

"If the physician has a contract with us, we are honoring that contract," said Kevin O'Neill, vice president for medical affairs and network management for CareFirst. "I don't think MedChi has reason to be as inflammatory as they are."

But T. Michael Preston, executive director of the medical society, said that while his group does not have comprehensive data on Shore claims, the anecdotal evidence is that the problem is getting worse, not better.

For example, Cindy Dowdy, administrator of the Chesapeake Cardiology Clinic, a five-doctor practice with offices in Easton and Cambridge, said CareFirst has paid about half its Medicare claims submitted this year. CareFirst's Medicare enrollees account for 11 percent of the practice's business, she said, but 28 percent of its accounts receivable.

"Payments have been slowed since December, and came to a grinding halt in May," she said. When the practice threatened in May to complain to the insurance administration, she said, CareFirst sent several checks with March dates.

O'Neill said CareFirst fell behind beginning in November when Doctors Health Inc., of Owings Mills, with which CareFirst contracted to oversee Medicare services on the Shore, filed for bankruptcy protection. "It took about a month and a half to get that sorted out" and resume paying claims, he said.

Then, in January, several other Medicare HMOs left the state, leading to an "explosion in enrollment," with its statewide Medicare HMO membership going from 28,000 to 45,000. That delayed payment as well, because "we can only add claims adjudicators so fast," O'Neill said.

Spiggle said while the Eastern Shore dispute may stem from particular causes, "the whole problem of nonpayment by health plans is not limited to CareFirst." An internal medicine doctor who practices in Cumberland, Spiggle said payment is slow in Western Maryland as well.

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