Author Topic: Late Filing Appeal  (Read 4668 times)

redeyecherry

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Late Filing Appeal
« on: March 29, 2010, 11:20:34 AM »
Is there any use in appealing a claim, which was denied because of late filing, with office notes from that date?
The DOS was 5/9/08, it wasnt billed til 10/30/09! So it was late filed and we have no proof of timely filing. I work at a Doctors office and the office manager wants me to rebill it with office notice.

answers appreciated :)

blhoffman

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Re: Late Filing Appeal
« Reply #1 on: March 29, 2010, 12:35:29 PM »
First you need to check the timely filing guidelines of the insurer. Look for any loopholes.
Is this Primary, Secondary or Teritary?
Then you need to contact the insurer and ask them to check in the patient's history on their system to find out when was the last time someone called about the date of service in question. (This information can be used in the appeal letter for reference.)
Verify the claim was never on file.

If the claim was never called about, not on file and truly untimely then there is nothing more you can do about it.

I also worked at an office that demanded we appeal everything. The idea was that the appeal is the final level and if denied then we have the backup for the write off. Do I agree with this method? No. Some situations do not call for an appeal but I do not argue with management. I do however make a note I am making the appeal at the request of said management.

medauthor

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Re: Late Filing Appeal
« Reply #2 on: March 29, 2010, 06:17:47 PM »
This wasn't Medicare, right???  Because if so, you would have until 12/31/09 to file the claim...just checking  :)
Michelle Rimmer, CHI, CPMB
President-Professional Medical Billers Association
Owner-ABA Therapy Billing Services
Author, 'Medical Billing 101' and 'Coding Basics: Understanding Medical Collections

Michele

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Re: Late Filing Appeal
« Reply #3 on: March 29, 2010, 08:51:21 PM »
Appealing with the office notes for a timely filing denial is not going to help.  They are saying the claim wasn't submitted timely.  The appeal would either have to show proof that it was filed timely, or give a very good reason as to why it wasn't filed timely.

Michele
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redeyecherry

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Re: Late Filing Appeal
« Reply #4 on: March 30, 2010, 11:05:38 AM »
Thanks a bunch for the answers, just making sure i am not wrong in my assumption ;)

DMK

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Re: Late Filing Appeal
« Reply #5 on: March 31, 2010, 10:48:39 AM »
And the public wonders why doctors go out of business!!! Sorry you're having to clean up the mess.  Just tell the doctor what the rules are about filing timely and that ANY payments you get should be considered gravy!  What were they thinking by not billing?   Oh well, some doctors are great doctors and horrible business people.  You'll be the hero for filing the new stuff timely and getting paid fast!

Dina

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Re: Late Filing Appeal
« Reply #6 on: April 03, 2010, 01:28:49 PM »
I always say "GO FOR IT" if you have nothing to lose. I used to be a claims examiner for 3 large carriers and we had a lot of administrative power, many times I would pay a claim regardless of late filing, maybe it was a nice day and I was in a good mood to make the administrative decision to do so. My motto is to at least give it a shot :)
Linda Walker
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Pay_My_Claims

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Re: Late Filing Appeal
« Reply #7 on: April 04, 2010, 03:36:13 PM »
I always say "GO FOR IT" if you have nothing to lose. I used to be a claims examiner for 3 large carriers and we had a lot of administrative power, many times I would pay a claim regardless of late filing, maybe it was a nice day and I was in a good mood to make the administrative decision to do so. My motto is to at least give it a shot :)

That's sad that claims are paid that way. It shouldn't be at the "discretion" of an adjuster.

PMRNC

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Re: Late Filing Appeal
« Reply #8 on: April 04, 2010, 05:32:33 PM »
Quote
That's sad that claims are paid that way. It shouldn't be at the "discretion" of an adjuster.

Why isn't that fair? It's not like they see a claim that is within the timely filing period and they deny it, I'm talking about the times the adjuster looks the other way and allows something using their judgment. All of the big carriers work that way. The more experience and years you have in, the more administrative thresholds you have, flip it around, suppose a procedure was to be cut for U&C and the examiner was allowed to override it. See works both ways. It is fair. It keeps examiners honest by allowing them more control for earned experience. The alternative is that the claim gets denied, so why is it not fair?
Linda Walker
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Pay_My_Claims

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Re: Late Filing Appeal
« Reply #9 on: April 04, 2010, 08:35:34 PM »
(Never mentioned not fair) No, I don't see the both ways in it according to what you posted. you said, you would be in a good mood and may let it slide. If the claim denied for timely filing, then I screwed up and I have to pay the penalty. The more you talk the more I feel justified in having investigations in insurance practices and procedures. Its no more right to pay a claim that should have been denied for timely filing, then to deny a claim because some adjuster is on their period. This is why you have contracts. If I follow the rules of the contracts, if I bill the claim timely and correctly, it should pay according to my contract and not some adjusters mood.

oneround

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Re: Late Filing Appeal
« Reply #10 on: April 05, 2010, 02:08:42 AM »
I see the glass half empty and half full.  With Linda I agree and somewhat disagree.  When I was in claims my staff were given the discreation of allowing a claim past timely only in a few exceptions, one being taking into account were there any recent holidays that may have prevented a delay in mail delivery?  If an EDI claim we allowed two to three days max, period!  Any other then that all denials for untimely, especially HMO senior claims, came to me for denial signoff.  That was not an adminastrative decision, but a upper management decision.  The problem for all starts when CIA does their audit, finds out money was paid out on an untimely claim, and I can guarentee you, they are ging to ask for their money back.  I give you 2000 and find out I did not really owe it to you, I want it back.

With Char, I agree that is why we have contracts, the provider signs and the provider must obide, file late don't get paid, but as I have mentioned above, most carriers inspite of their contracts, make somewhat of an exception, not based upon what time of the month it is though., Compliance issue, umph, I would'nt go out that far to say becuase here no underpayments and or fraud  happening and I really don't think that the provider would argue the case because hey, it's Friday night and they just got paid.  Pay my claims late and I guaruntee you I'm renewing next year.  I think it would be more of a corrective acton issue if it was against company policy.  Just my opinion.  You ladies are funny, but I really do value your expertise.  Linda, Char, Michelle and all else.
Michael A. Reynolds, CPC, CCP-P, CPMB, OS
Project Manager
Corporate Compliance
Sharp HealthCare

PMRNC

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Re: Late Filing Appeal
« Reply #11 on: April 05, 2010, 07:35:51 AM »
There are MANY known carrier "Administrative Decisions" to be had. They are perfectly legal and necessary. When you have THOUSANDS of claims coming onto a claims floor every day, it's essential to have certain administrative decision makers.  Not every instance would claim an administrative decision.. for example Eligibility issues.. if a patient is terminated the claims system WILL not allow a bypass. With Late filing..EVERY INSURANCE CARRIER covers their butt with their "Timely filing guidelines" however a claims system will allow a bypass for those grey areas.. and allow for an administrative decision.  The same goes for claims over U&C, depending on the claims examiners threshold a dollar value bypass can be done..   In other words there are certain things that can be over-rided due to an administrative decision. Now if you get a claim paid that shouldn't have been for another issue in which this wasn't allowed that is different. If you get paid on a claim that was maybe a month past late filing and you want to send it back, go for it!  Just a question..but if there were no allowances for administrative decision making.. why bother appealing the claim anyway, just chalk it up as a learning experience? Not very flexible.
Linda Walker
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Pay_My_Claims

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Re: Late Filing Appeal
« Reply #12 on: April 05, 2010, 05:22:19 PM »
There are MANY known carrier "Administrative Decisions" to be had. They are perfectly legal and necessary. When you have THOUSANDS of claims coming onto a claims floor every day, it's essential to have certain administrative decision makers.  Not every instance would claim an administrative decision.. for example Eligibility issues.. if a patient is terminated the claims system WILL not allow a bypass. With Late filing..EVERY INSURANCE CARRIER covers their butt with their "Timely filing guidelines" however a claims system will allow a bypass for those grey areas.. and allow for an administrative decision.  The same goes for claims over U&C, depending on the claims examiners threshold a dollar value bypass can be done..   In other words there are certain things that can be over-rided due to an administrative decision. Now if you get a claim paid that shouldn't have been for another issue in which this wasn't allowed that is different. If you get paid on a claim that was maybe a month past late filing and you want to send it back, go for it!  Just a question..but if there were no allowances for administrative decision making.. why bother appealing the claim anyway, just chalk it up as a learning experience? Not very flexible.

Linda, but that isn't what you said...you said "look the other way" . I agree in how "oneround" put it. There were allowances made. These are not made on the "mood" of the adjustor as you put it in your reply. Simply put there is no no reason a provider should be 366 days behind on his billing. I am dealing with a provider TODAY that has such issues. I have 2 providers calling for my services for claims because their AR is >120 days old. I have 1 claim I am working on today that was from 02/18/08 where BCBS paid for everything but the base. They didn't pay the last line (page) of the claim. I am working to get that appealed. One thing on my side is the claim was processed and filed timely. We have been back and forth with this claim in appeals since 2008. Each payment drags in.  I don't waste time with timely filing denials that I DID not file on time. What is the point in that. I will send in the claim for payment, if it denies, I may appeal it for some bs reason, and if it denies...what do I have to complain about??

You need to READ what I wrote because you are all out in left field. My point is...I AGREE there should be allowances, (client is 1 day late for timely filing, claim was filed but required information not sent with claim etc etc) You can be flexible...I AGREE, but that mood stuff you spoke of in our ORIGINAL post just dont sit right with me. So no, I would not send a claim back that got paid that was past timely filing....

 ???

PMRNC

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Re: Late Filing Appeal
« Reply #13 on: April 05, 2010, 06:09:51 PM »
Yes, I probably mis-spoke, because I tell it like it is. I SHOULD have said we made administrative decisions, but what I told you is the way it is, whether it sits right with you or not, I can't help it.. lol  I've worked in a few diff claims departments and that does go on.. I could go into more detail but then you really wouldn't be sitting too well. Bottom line is that the claims examiner holds more power than you know.. that's why you will ALWAYS catch me being super nice to them because I know what they can and can't do.

But if it makes you feel better, I will tell you that our guidelines just simply allowed for administrative decisions upon careful review of circumstances. Is that better? 
Linda Walker
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Pay_My_Claims

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Re: Late Filing Appeal
« Reply #14 on: April 05, 2010, 07:22:25 PM »
Yes, I probably mis-spoke, because I tell it like it is. I SHOULD have said we made administrative decisions, but what I told you is the way it is, whether it sits right with you or not, I can't help it.. lol  I've worked in a few diff claims departments and that does go on.. I could go into more detail but then you really wouldn't be sitting too well. Bottom line is that the claims examiner holds more power than you know.. that's why you will ALWAYS catch me being super nice to them because I know what they can and can't do.

But if it makes you feel better, I will tell you that our guidelines just simply allowed for administrative decisions upon careful review of circumstances. Is that better? 

Nope, now that the inside info has been revealed, I will definitely be more pro-active in my fight. I knew insurance companies were crooked anyway, now I just have the inside confirmation!! I will have them pull THEIR files to see what was done, and have audits of their accounts....see how they like a lil shug avery pee in their throats!!