HMO/PPO Duties

When a doctor or other medical professional provides medical care to a patient, they typically file a claim with their patient’s insurer in order to receive reimbursement for their work. Insurance companies are expected to process these claims in a timely fashion and pay medical service providers the appropriate amount for their services. However, far too many insurers take advantage of their position, delaying or refusing to pay doctors for their services.

In these circumstances, it may be possible for medical care providers to pursue legal action against insurers under the Texas Prompt Pay Act. If you are a doctor or other medical professional in Texas who has not received the payments that are owed to you, our team at Williams Kherkher knows how frustrating this can be, but wants you to know that there are options available to you to get the compensation you deserve.

Duties Owed by HMOs/PPOs

When a medical care provider files a “clean claim” with a patient’s insurance company, the company has four available options:

  • Pay the claim in full, per the company’s contract with the physician
  • Deny the claim, providing the physician with appropriate reasoning
  • Pay the claim but perform an audit, notifying the physician that an audit is being performed
  • Pay part of the claim and deny or audit the remainder

Depending on which option the insurance company chooses to pursue, there is a strict timeline in which the provider must be fully compensated for their claim. If the insurance company fails to provide reimbursement within this period, or if they wrongfully deny the physician’s claim, legal action may be necessary in order to ensure that justice is served.

Learn More about HMO/PPO Duties from a Prompt Pay Lawyer in Texas

If you are a medical service provider and are encountering difficulties in receiving appropriate compensation from an insurer, you may be entitled to pursue a Prompt Pay claim in order to recover the compensation you are due. At Williams Kherkher, our lawyers are dedicated to helping medical providers in this situation and may be able to help you. Find out more about your legal options by calling (888) 220-0640.

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