Texas Medical Billing Audit & Prompt Pay Act Enforcement
Leverage statutory Texas Department of Insurance (TDI) prompt pay penalties (up to 100% plus 18% statutory interest) to force commercial health plans to adjudicate clean medical claims within 30 days.
Texas practices operate under one of the strongest state prompt-payment statutes in the United States—the Texas Prompt Pay Act (Tex. Ins. Code Ch. 1301/843). Commercial insurers (BCBSTX, UnitedHealthcare, Aetna, Cigna) are statutorily required to pay clean electronic claims within 30 calendar days (45 days for paper claims). If a carrier fails to pay or systematically underpays without statutory notice, the provider is legally entitled to penalty payments ranging from 50% to 100% of the contracted fee plus 18% annual interest. Our forensic Texas audit uncovers claims held in artificial "review" loops, audits PPO network affiliation claims, and files formal TDI complaints that unlock trapped Texas practice cash flow.
Audit red flags
- Texas commercial payers withholding payment beyond 30 days without issuing formal electronic deficiency notices.
- Silent PPO repricers (MultiPlan, Zelis) applying out-of-network discounts without a valid participating agreement on file in Texas.
- Medicaid Managed Care Organizations (Superior, Parkland Community Health) denying authorizations after inpatient or specialty admission.
- Clearinghouses routing Texas clean claims through secondary repricing networks that strip statutory prompt pay rights.
Audit action plan
- 1. 30-Day Clean Claim Date-Stamp Audit — Extract clearinghouse 837 electronic transmission timestamps to identify all claims pending beyond 30 days without statutory denial explanations.
- 2. TDI Chapter 1301 Penalty Calculation — Automate calculation of statutory 50% to 100% penalty damages and accrued 18% interest on overdue Texas commercial balances.
- 3. Formal Texas Department of Insurance Escalation — Submit batch TDI regulatory enforcement filings compelling carrier provider relations executives to resolve aged accounts.
Codes reviewed
- 99214 — Office Outpatient Established Visit (Level 4)
- 99215 — Office Outpatient Established Visit (Level 5 High Complexity)
- 80053 — Comprehensive Metabolic Panel In-Office
- 36415 — Routine Venipuncture Collection
Frequently asked questions
What qualifies as a clean claim under the Texas Prompt Pay Act?
A clean claim includes all required CMS-1500 or UB-04 data elements, valid NPI, matching ICD-10 and CPT codes, and verified patient member IDs submitted electronically through an accredited clearinghouse.
Does the Texas Prompt Pay Act apply to self-funded ERISA employer plans?
Self-funded employer plans are governed federally by ERISA Section 502(a) rather than state insurance codes. However, our forensic audit pairs TDI state enforcement for insured commercial plans with ERISA federal breach of fiduciary duty appeals for self-funded plans.