Author Topic: Appeals for Not Filing In Timely Manner  (Read 2474 times)

dfranklin

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Appeals for Not Filing In Timely Manner
« on: October 18, 2009, 08:05:45 PM »
I recently signed up a new chiropractor and their previous billing company really screwed up their billings.  There were about 1000 claims that did not get filed.  I am filing all of these claims for them but my question is I am getting responses on the older ones that they are not paying them due to receiving the claim after the Timely Filing Limitation.  I was wondering if we could appeal this asking for an exception due to their circumstances.  Has anyone done this?  Any have suggestions on what to say in the letter or how to go about doing this?  There are quite a few so there is a good amount of money the doctor is losing on this.  Also since there are mulitple claims per carrier that are not paid for the timely filing reason can you appeal them together in one letter and submit the letter with multiple claims in the envelope or do you have to do one letter for each claim per envelope?

Thanks in advance for your help!

Priyan

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Re: Appeals for Not Filing In Timely Manner
« Reply #1 on: October 19, 2009, 02:39:31 AM »
To be frank I havent tried for a claim which is not filed even once in past and now first filing denied for Untimely.

But, We can do it this way. We wouldnt have received rejections from Medicare, Medciaid and non par insurance as well as we have minimum of 1yr from dos. For medicare we have lot more by calender yr calculation.

For the contracted insurance companies, we can speak to our assigned provider relation representative as we had a system glitch that electronic claims did not go out of system. They will definetly Help us in getting atleast a 50-60% of avg after late filing reductions.

Again, this may work for us. Keep me adviced on the results or any different views
Priyan.D
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PMRNC

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Re: Appeals for Not Filing In Timely Manner
« Reply #2 on: October 19, 2009, 06:21:12 AM »
It depends on HOW old. Medicare won't budge on timely filing denials. Some carriers you can appeal based on circumstances but make sure you include an appeal letter and again it depends on how old. If the carrier has to go to Microfiche..they don't like doing that it requires the examiner to get out of their chair.  :o

I've had success with timely filing appeals with a few carriers. If you get the patient or insured in on it you have a better chance. The carriers do have some sort of administrative decision making so it's not hopeless, just a bit difficult the older the claims are.
Linda Walker
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Michele

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Re: Appeals for Not Filing In Timely Manner
« Reply #3 on: October 19, 2009, 06:25:10 AM »
We too have encountered similar situations.  If there is a provider rep that is the way we went.  Explained to them what happened, submitted all claims affected to their attention, and they got them all processed.  When the company didn't have a provider rep we would submit them with a cover letter explaining that the provider is unsure as to if the claims had been attempted to be submitted or not, and explained the situation where the provider had a biller/service that they had realized was not handling claims properly so they had called us in.  We would ask them to consider the claims even if they were past the filing limit since the provider was unaware of the situation.  Basically, it is still the provider's responsibility but some carriers did make the exception.

Michele
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Michele

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Re: Appeals for Not Filing In Timely Manner
« Reply #4 on: October 19, 2009, 06:26:46 AM »
When I used to work for a major insurance carrier I loved a reason to get out of my chair!  But most of my co workers didn't.  :(  Of course most of my job was fixing their mistakes!  LOL

Michele
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PMRNC

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Re: Appeals for Not Filing In Timely Manner
« Reply #5 on: October 19, 2009, 08:53:45 AM »
I hate telling people sometimes of what goes on as a claims examiner.. many times the difference between paying and denying a claim came down to the mood I was in and the easiness level. Most may not know but examiners are rated on not just quality but production, it was not unheard of to take your daily batch's and break out the easy claims to process first and leave the crap for overtime or after you hit your daily production. The longer you have been there and the better your stats the more administrative authority you had and the higher payment threshold.. for example I was at USLife (now AGI) for 9 years, I had a payment threshold of $75,0000 without going to quality check. Only random claims would go to Quality check and they could be $50 claims. LOL We also had mandatory overtime, so the more we were forced to work the faster we pushed out claims and that would often mean applying something we were taught.. "IF in doubt.. Knock it Out"  (claims examiner talk to deny the claim and worry about it on appeal.) I know it's horrible. Not justifying it or excusing it but goes on and I think that's why I've been successful on the other side because I do know these little things.   In regards to late filing, again, if the claim had to be looked up, researched and it required a lot of work, I had the administrative authority to deny it based on timely filing, but many times I would go back to some of these claims after my production was hit and then pay a lot of them.. again, it depended on the day!
Linda Walker
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Michele

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Re: Appeals for Not Filing In Timely Manner
« Reply #6 on: October 20, 2009, 07:35:01 AM »
Or, like where I worked, it was easier to just pay the claim (late filing) rather than research it!  So again, it will all depend on the person's desk it lands on.  I agree with Linda, not justifying how things are done, just explaining it.  Knowing how things are handled helps to work it from this side.  I hated how it worked from that side and that's what drove me to do this business.  They gave me the authority to make decisions that I had no business making. 

Michele
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