Medical Billing Forum

Billing => Billing => Topic started by: redeyecherry on March 29, 2010, 11:20:34 AM

Title: Late Filing Appeal
Post by: redeyecherry 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 :)
Title: Re: Late Filing Appeal
Post by: blhoffman 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.
Title: Re: Late Filing Appeal
Post by: medauthor 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  :)
Title: Re: Late Filing Appeal
Post by: Michele 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
Title: Re: Late Filing Appeal
Post by: redeyecherry on March 30, 2010, 11:05:38 AM
Thanks a bunch for the answers, just making sure i am not wrong in my assumption ;)
Title: Re: Late Filing Appeal
Post by: DMK 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
Title: Re: Late Filing Appeal
Post by: PMRNC 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 :)
Title: Re: Late Filing Appeal
Post by: Pay_My_Claims 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.
Title: Re: Late Filing Appeal
Post by: PMRNC 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?
Title: Re: Late Filing Appeal
Post by: Pay_My_Claims 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.
Title: Re: Late Filing Appeal
Post by: oneround 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.
Title: Re: Late Filing Appeal
Post by: PMRNC 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.
Title: Re: Late Filing Appeal
Post by: Pay_My_Claims 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....

 ???
Title: Re: Late Filing Appeal
Post by: PMRNC 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? 
Title: Re: Late Filing Appeal
Post by: Pay_My_Claims 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!!
Title: Re: Late Filing Appeal
Post by: Michele on April 05, 2010, 08:26:50 PM
When I worked for a major insurance carrier timely filing appeals were at the sole discretion of the approver who happened to get the appeal.  Not much in the way of guidelines.

Michele
Title: Re: Late Filing Appeal
Post by: PMRNC on April 05, 2010, 08:48:51 PM
Quote
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!!

You be sure to let me know how that works for you. Remember again, we are talking about claims that SHOULD be denied and get paid .. Never did I say we arbitrarily deny claims or cut claims beyond the rules. So what will you be fighting? You going to tell the claims person that you are upset they paid your claim they should have denied?

Here's a few examples..  Claim is entered by claims examiner, it comes up 15 days past late filing. Claims examiner checks microfilm to see if possibly it was denied or pending, it's not, but the examiner looks out the window and is reminded that it's 5:00 and it's beautiful out and she has dinner plans and she's in a good mood and she decides to let your 15 day discretion go and overide the denial.  OR ..    Claims examiner looks out window, it's raining and shitty outside and she has to put in her 2 hours mandatory overtime for the week that night and she decides..Nope, it's not within timely filing and your not getting paid.    So with either of that scenario., what are you going to do? Yell at her for paying it, or yell at her for doing her job?

I think you are confused about what I was talking about.. I never said we made up our minds to deny a claim based on a good mood or not. But if it really riles you up to know that a good mood will get a claim that should have been denied paid.. by all means get fired up.
Title: Re: Late Filing Appeal
Post by: PMRNC on April 05, 2010, 08:55:46 PM
Quote
When I worked for a major insurance carrier timely filing appeals were at the sole discretion of the approver who happened to get the appeal.  Not much in the way of guidelines.

YES exactly Michele. I'm scratching my head wondering why anyone would be upset over a "gift" of kindness from a claims examiner in a good mood. LOL  Actually you named the title given exactly it was called "Examiner discretion" The longer you worked there the more you had. No where is it written that any claims person arbitrarily, and depending on mood DENY or cut a claim using discretion. I never even suggested or hinted that in any of my posts.   
Title: Re: Late Filing Appeal
Post by: Pay_My_Claims on April 05, 2010, 09:45:34 PM
Quote
When I worked for a major insurance carrier timely filing appeals were at the sole discretion of the approver who happened to get the appeal.  Not much in the way of guidelines.

YES exactly Michele. I'm scratching my head wondering why anyone would be upset over a "gift" of kindness from a claims examiner in a good mood. LOL  Actually you named the title given exactly it was called "Examiner discretion" The longer you worked there the more you had. No where is it written that any claims person arbitrarily, and depending on mood DENY or cut a claim using discretion. I never even suggested or hinted that in any of my posts.   

LOL, hold on..I NEVER said I was upset that they paid the claim. By your OWN words, the claim should have denied, and if it did because I screwed up, I would NEVER be upset over my error. I was CLEAR when I said, that it should not be based upon the "mood" of the adjuster. The confusion came from YOUR post in how you worded it. It is not right, whether it is normal insurance practices or not, that isn't my point. And YES you did say that. You said If you were having a good day or in a good mood. Please re-read your post...better yet.. 

Quote from: PMRNC 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 Smiley

Now although you have administrative rights to make decisions on claims payment, you inferred that that decision can be based on your mood. I CLEARLY stated that it should not be. Just as you can be in a "good mood" and let my claim that is 60 days past due pay, you can also DENY my claim that is One day late, because CLEARLY policy dictates that it is late, and it can deny.
Title: Re: Late Filing Appeal
Post by: blhoffman on April 05, 2010, 09:47:32 PM
I have to laugh ;D

I have a claims processing background also in some of the largest insurance companies and it is all true. I can tell you without a doubt that we have timely filing guidelines and I did have the power to make a judgement call on whether something would be paid or not after my research. There are multiple reasons and not "mood" on why I would give consideration. Just like any job sometimes common sense has to play a role. Life is not black and white - it is all shades of grey.
Example:

You send something in timely. Call the insurance and told it is not on file. You send it again. Told it is not on file. Now you are past timely. You submit the claim anyways. I receive it and in your letter, you state you spoke to so-and-so. Swearing you submitted and so-and-so was looking into it and you never received a call back and blah, blah, blah.

Red flag went up as soon as I seen name so-and-so. You as the biller for a provider do not know that me as a claims processor, happens to know that so-and-so was under investigation and was just fired three days ago because so-and-so was not doing her job. Will I consider your request - YES  ;D
Common sense and judgement tells me that you are possible right because 'I' have the inside scoop.
Title: Re: Late Filing Appeal
Post by: Pay_My_Claims on April 05, 2010, 09:52:13 PM
I have to laugh ;D

I have a claims processing background also in some of the largest insurance companies and it is all true. I can tell you without a doubt that we have timely filing guidelines and I did have the power to make a judgement call on whether something would be paid or not after my research. There are multiple reasons and not "mood" on why I would give consideration. Just like any job sometimes common sense has to play a role. Life is not black and white - it is all shades of grey.
Example:

You send something in timely. Call the insurance and told it is not on file. You send it again. Told it is not on file. Now you are past timely. You submit the claim anyways. I receive it and in your letter, you state you spoke to so-and-so. Swearing you submitted and so-and-so was looking into it and you never received a call back and blah, blah, blah.

Red flag went up as soon as I seen name so-and-so. You as the biller for a provider do not know that me as a claims processor, happens to know that so-and-so was under investigation and was just fired three days ago because so-and-so was not doing her job. Will I consider your request - YES  ;D
Common sense and judgement tells me that you are possible right because 'I' have the inside scoop.

Yup, and I agree, I know it goes on, but that "mood" thing just made my blood boil. Its just one of me and Linda's usual agree disagree, agree. disagree sessions....LOL
Title: Re: Late Filing Appeal
Post by: blhoffman on April 05, 2010, 10:02:06 PM
True situation - I cannot tell a lie ;)

Little old woman calls in - went to wrong lab - I do a "Pay & Educate". Pay the claim, give correct lab info. and address. Next month - Little old woman calls in and asks for me by name. Good lord have mercy, she has my name now.
Little old woman went to wrong lab again - same wrong lab. Then confides it is at the end of the block and her daughter could not take her to correct one. Little old woman is 86 years old and only one she can walk to. Aagghh! I do a "Pay & Educate".

Supervisor stops me one day and says "why did you do 2 Pays & Educate for Little old woman. I look down at floor and sigh very deeply and say " Little old woman refuses to be educated!"
Title: Re: Late Filing Appeal
Post by: PMRNC on April 06, 2010, 10:27:25 AM
Charlene, you clearly were upset and from this it looks like you completely missed the point I was making:

Quote
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!!

Again.. WHAT are you fighting? I don't understand where the above came from when we were discussing administrative decisions on overturning claim denials.. PAYING.. NOT DENYING??   I do understand you didn't like the remark about the good/bad mood.. but it is what it is., all I did was speak about what goes on, doesn't mean I think it's right either. I mean come on, it's sort of common knowledge that if you are not nice to the claims people or put them in a bad mood you are not going to get any further than being told to put your appeal in writing.

 I will, as usual be upfront in my admission that there have been times where I could have let a denial be overturned and I didn't. Also, I will admit that if someone called me on a claim that was processed and denied and I investigate and it was supposed to be denied, how that person treats me on the phone is going to make a difference if I decide to review and re-process the claim in their favor (as long as the denial was justified). Case in point.. I remember one day a physicians office called up customer service and after they were screaming and yelling at the claims rep for over half an hour the call goes to the next on the totum pole.. the claims examiner that processed the claim..that would be me. The first thing they say to me is "You Bastard's are not going to get away with ripping me off". Calmly I get them to give me a minute, pull up the claim, review it and low and behold it was Surgical fee cut by $400 due to R&C guidelines.  Now there's a lot that goes into U&C / R&C guidelines and again.. examiners have some administrative decision discretion.. I actually could have reviewed the claim and overrided the U&C to pay out the full $400 However after being called so many 4 letter words I just repeated the standard, send in your appeal within 30 days..blah blah blah.    That's just one of many.

Now if I was in a BAD mood .. no matter what, I couldn't and didn't deny claims arbitrarily..

So what I'm saying is I just do NOT get where you think you need to use the info I gave you as a means to FIGHT more diligently? That will get you as far as that office manager trying to get an additional $400 from me.

Title: Re: Late Filing Appeal
Post by: Pay_My_Claims on April 06, 2010, 06:27:20 PM
OMG, this is so overdone. You went off on the Tangent Linda, when my reply was yes in reference to your post about the mood. You keep talking over and over and over the subject that was at hand.  when all I said was its sad that claims are paid according to mood (which you said you didn't say) and now you are agreeing with me..LOL. OMG I just can't win. I'm so done!!!