Author Topic: Late Filing Appeal  (Read 4836 times)

Michele

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Re: Late Filing Appeal
« Reply #15 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.

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PMRNC

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Re: Late Filing Appeal
« Reply #16 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.
Linda Walker
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PMRNC

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Re: Late Filing Appeal
« Reply #17 on: April 05, 2010, 08:55:46 PM »
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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.   
Linda Walker
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Pay_My_Claims

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Re: Late Filing Appeal
« Reply #18 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.

blhoffman

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Re: Late Filing Appeal
« Reply #19 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.
« Last Edit: April 05, 2010, 09:49:08 PM by blhoffman »

Pay_My_Claims

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Re: Late Filing Appeal
« Reply #20 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

blhoffman

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Re: Late Filing Appeal
« Reply #21 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!"

PMRNC

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Re: Late Filing Appeal
« Reply #22 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.

Linda Walker
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Pay_My_Claims

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Re: Late Filing Appeal
« Reply #23 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!!!