This bill aims to significantly improve payment timeliness for healthcare providers by Medicare Advantage (MA) organizations. It mandates that MA organizations must provide prompt payment for at least 95 percent of all "clean claims" submitted by providers and suppliers. This requirement applies to services furnished to enrollees, regardless of whether the provider is in-network or out-of-network. The bill establishes specific payment deadlines: 14 calendar days for electronically submitted claims from in-network providers and 30 calendar days for all other claims. A "clean claim" is defined as one with a complete data set according to standard forms and, for electronic submissions, compliant with applicable electronic standards. If an MA organization fails to meet these deadlines, it must pay interest to the provider, and the Secretary may impose civil money penalties of up to $25,000 for each non-compliance determination. To enhance transparency and oversight, MA organizations must provide detailed information to the Secretary regarding their prompt payment performance. This includes data on the number and percentage of claims paid on time, distinguishing between in-network and out-of-network providers, and the total interest paid due to late payments. These new requirements will take effect for items and services furnished on or after January 1, 2027.
This bill aims to significantly improve payment timeliness for healthcare providers by Medicare Advantage (MA) organizations. It mandates that MA organizations must provide prompt payment for at least 95 percent of all "clean claims" submitted by providers and suppliers. This requirement applies to services furnished to enrollees, regardless of whether the provider is in-network or out-of-network. The bill establishes specific payment deadlines: 14 calendar days for electronically submitted claims from in-network providers and 30 calendar days for all other claims. A "clean claim" is defined as one with a complete data set according to standard forms and, for electronic submissions, compliant with applicable electronic standards. If an MA organization fails to meet these deadlines, it must pay interest to the provider, and the Secretary may impose civil money penalties of up to $25,000 for each non-compliance determination. To enhance transparency and oversight, MA organizations must provide detailed information to the Secretary regarding their prompt payment performance. This includes data on the number and percentage of claims paid on time, distinguishing between in-network and out-of-network providers, and the total interest paid due to late payments. These new requirements will take effect for items and services furnished on or after January 1, 2027.