State orders measure to help small health care providers in wake of cyberattack [The Santa Fe New Mexican]

Mar. 25—State officials hope ordering insurers to streamline their claims processes for small New Mexico health care providers will offer some relief to companies still reeling from a recent and particularly devastating cyberattack.

The attack on health care technology giant Change Healthcare, which handles about half of all medical claims in the U.S., came to light in February and has yet to be fully resolved. The firm, owned by UnitedHealth Group, has largely restored systems for handling pharmacy claims and processing payments, but it has yet to restore its software for submitting medical claims and has no timeline for that last leg of recovery, the Associated Press reported.

New Mexico Superintendent of Insurance Alice Kane last week ordered major insurance companies in New Mexico to temporarily halt several practices that are slowing down claims processes for small and independent providers. The order requires insurers to temporarily suspend prior authorizations, refrain from retroactively denying claims due to common issues caused by the cyber incident and waive "timely filing" policies that require providers to submit claims within a certain timeframe after services are performed, according to the state Office of Superintendent of Insurance.

The order also requires insurers to waive deadlines for claims and appeals submitted by small and independent providers after Feb. 21, the day the breach was discovered.

The measures are a welcome respite for small providers as the problems continue wreaking havoc on the ground, said Anne Jung, executive director of the New Mexico Medical Society.

"This was a very strong attempt by the superintendent to maintain the health care provision flow," Jung said. "You want to keep the access to health care. ... You don't want doctors' offices closing down because they can't make payroll, and you don't want them refusing to see patients because they don't know if they're going to get paid for that or not."

Many medical providers use Change Healthcare's clearinghouse services to process claims rather than using scant office employee resources to directly file claims to insurance companies. The attack broke that pipeline of digital information, leaving a communication gap where insurance companies don't know when to pay providers. Jung said some providers, in desperation to keep services and payments moving, reverted to filing paper claims, a time-intensive process insurance companies are struggling to keep up with.

Attempts to verify patients' benefits also have led to major bottlenecks as medical office workers across the country try to reach insurance companies by phone, Jung said.

"You have staff sitting on the phone for hours trying to check eligibility," she said. "You can imagine the screeching of the wheels that this caused."

Insurance companies, meanwhile, are in some cases sending lump payments to providers but are unable to provide the detailed explanation of benefits that typically would accompany those payments and specify which patients the money is paying for.

"So what has happened is that the practice might receive money, but no EOB, so they don't know where to credit that money to," Jung said. "So financially that's a problem."

Large health care providers are also affected, of course, but Jung said smaller providers have fewer resources to adapt their practices and generally have less financial wiggle room.

The end result has been a backlogged system that's stressing small providers' finances to the point Jung is hearing stories of doctors personally lending their practices money and clinicians temporarily going without paychecks, all in an effort to ensure they can continue to make payroll and keep the doors open.

"It'll catch up," Jung said. "But there's no true prediction of when it will catch up."

Jung said the insurance superintendent's order should help get things back in a more manageable state of affairs as Change Healthcare keeps trying to restore its systems. While providers moving forward with procedures without the ability to check patients' coverage first could lead to some reckoning after the systems are restored, Jung said, all the parties are moving ahead in "good faith."

"That's going to be probably a case-by-case [situation], but I think the intention was that it would be paid," Jung said. "Because it's not the doctor's fault. It's not the patient's fault. It's not the insurance company's fault. It's whoever hacked into Change Healthcare's fault."

The insurance superintendent's order was issued Wednesday and is set to stay in effect for 30 days.

The order applies to fully insured major medical plans in the individual, small group and large group markets. It doesn't apply to health care plans that the state Office of Superintendent of Insurance doesn't have authority over, including self-funded health plans, Medicaid, Medicare or Tricare, the uniformed services health care program.

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