"Law TakeCare cites to prevent GRMC billings is being misinterpreted"Written by Janela Carrera
Guam - TakeCare Insurance has fired back and is calling the Guam Regional Medical City bullies for attempting to drag them into what they call an unfair agreement. TakeCare is also referencing local law that they believe prevents the hospital from billing patients for claims over 90 days old.
But GRMC says the insurance company is misinterpreting the law and they have the law’s author to back them.
TakeCare Insurance is fighting back against GRMC’s attempts to collect from TakeCare customers’ past due bills, taking out full page ads in both daily papers. Signed by CEO Joe Husslein and President Jeff Larsen, the ad is addressed to TakeCare members, disputing GRMC’s public announcements about failed negotiations.
The letter is in response to GRMC’s public announcement that it would be billing TakeCare patients for services related to visits within the last two years.
But TakeCare is advising its members not to pay those bills right away and seek legal advice first. Citing local law called the Prompt Payment Act of 2000, TakeCare believes bills over 90 days old are invalid. Essentially, TakeCare is saying that if it’s been more than 90 days since your visit and you still haven’t received a bill, then you’re free and clear.
“GRMC’s threat to send stale bills to TakeCare’s members may be in violation of law, depending on when the services were provided,” TakeCare’s letter reads.
"Our interpretation is the Prompt Payment Act of 2000 was a law that was created to regulate the relationship between a contracted health plan and a provider particularly the hospital [Guam Memorial Hospital] at that time but it involves all providers," noted Plinske. "However he has taken the angle that, 'However, it does apply between the provider--GRMC--and our member,' our patient, their member, and we’re saying absolutely not it does not."
What does the law’s author, former Sen. Simon Sanchez, say? He explained his intent for the law on NewsTalk K57's One Free RePhill with host Phill Leon Guerrero.
"In terms of timely payment, this was aimed at healthcare providers and healthcare insurers, administrators that have a contract," said Sanchez.
In essence, Sanchez says the law requires that providers--in this case hospitals--submit claims or bills to the healthcare insurance agency within 90 days. But for TakeCare members this law would not apply. This is because GRMC and TakeCare do not have an agreement or contract in place.
"So if you’re a TakeCare customer, from a GRMC point of view, at least if you go there, you are a self-pay [patient]," noted Sanchez.
The claims referred to in the law that must be submitted within 90 days are ones that read in code and for the most part are usually handled by medical billers and coders.
"We’re talking about ICD10 diagnosis codes; were talking about common procedural terminology or CPT treatment codes; we’re talking about modifiers used depending on the type of care--all these are in codes on these claims forms," explained Plinske. "Do you think that, ok, we send a claim to [the individual] in 90 days and they’re gonna read all that stuff we just talked about? They don’t know what the codes are."
As far as being called a bully, Plinske had this to say: "Somehow they become the victim. TakeCare’s the victim, we’re the bully. I don’t know what they refer to their patients as I think, let’s relook at things here, the victim is the patient--their member is the victim."
You can read TakeCare's letter to its members in full below:
TakeCare is an insurance company with over 40 years of experience in facilitating quality medical care for its Members. As part of this process, TakeCare regularly enters into agreements with leading US and internationally accredited hospitals, including hospitals in Hawaii, the U.S. mainland and the Philippines, and always does its best to negotiate reasonable rates for its Members.
On Guam, TakeCare has a long-standing relationship with Guam Memorial Hospital (GMH). However, TakeCare does not have an agreement with Guam Regional Medical City (GRMC) because GRMC's rates for services are substantially higher for equivalent services at GMH. For example, the daily room rate at GMH is approximately $600, while a daily GRMC rate is approximately $2,400. GRMC’s rates are an astounding 4 times higher than GMH!
If TakeCare agreed to pay GRMC’s excessive rates, the increased cost of care would simply be passed on to TakeCare Members by increased premiums. TakeCare, at the request of its employer groups, has offered to extend coverage for services at GRMC via a benefit rider with a corresponding additional premium adjustment. In the end, TakeCare’s customers have decided to forgo such GRMC coverage. In short, TakeCare’s customers clearly see no value in having access to GRMC and the resulting higher costs.
Recent media reports generated by GRMC falsely claim that TakeCare owes GRMC millions of dollars for care provided to TakeCare Members. This is simply not true. GRMC admits it does NOT even have an agreement with TakeCare. Without an agreement, GRMC is not a part of TakeCare's provider network, and GRMC does not have the contractual right to bill TakeCare for services it provides to TakeCare Members. Therefore, it is impossible for TakeCare to owe money to GRMC.
Even though GRMC does not have an agreement with TakeCare, we have always reimbursed members at the same usual, customary rate paid to GMH for bona fide emergency services subject to the terms of its policies. TakeCare treats GRMC consistent with industry practices when bona fide emergency services are required, whether on- or off-island, at non-participating hospitals. Our research shows that only a small fraction of the alleged outstanding claims are for bona fide emergency services GRMC provided to TakeCare Members.
In addition to charging unreasonable rates, GRMC, through its own omission, has also failed to submit many bills for services to its patients, including TakeCare Members, in a timely manner as required by law. The Health Care Prompt Payment Act of 2000 (Title 10 Guam Code Annotated §§ 9901-9908), requires that GRMC submit accurate claims within 90 days from the date that health care services were provided. Under most circumstances, claims not submitted within 90 days from the date of services cannot be collected from either a patient or his/her insurer. Consequently, GRMC's threat to send stale bills to TakeCare's Members may be in violation of law, depending on when services were provided.
TakeCare has made several good faith efforts to settle disputed claims and to negotiate reasonable rates with GRMC so that it can be included in its provider network. To date, these efforts have not been successful because of the unreasonable positions taken by GRMC. GRMC's misrepresentations about TakeCare in the media, and threats to TakeCare Members, are just the latest maneuvers designed to bully TakeCare into an unfair agreement which would not be in the best interest of its Members. TakeCare will continue to insist upon reasonable rates before any agreement can be reached with GRMC.
TakeCare recommends that any Member receiving a bill from GRMC to contact TakeCare Customer Service at 647-3526 for information and assistance. Customer Service will help explain Members' rights and responsibilities under its health plans as well as help to review GRMC's billings for accuracy. Members may also wish to consult with legal counsel regarding their rights against GRMC for trying to collect on untimely claims that may be barred by Guam law.”