Over the limit denial. Can biller be held accountable?

[TN Doc]

I have a small practice and hired a new biller, who came highly recommended by a colleague.  Despite numerous inquires as to the status of my claims, she finally submitted them, but they were over the 90 day limit.  There is no appeal process since it was her error.    She stated that I need to write the $950 off.  I feel that it is only fair that she write it off against my balance that I owe  her. 
Unfortunately we have no contract and I doubt that she has errors and omissions insurance.  Any feedback would be appreciated. Thank you!

[Michele]

Wow.  So sorry that you are having such a bad experience.  Unfortunately not all billers do a good job.  You are in a tough spot but here are a couple of suggestions.  First, do you know why the claims were not submitted sooner?  Was there a valid reason that could be used as an appeal?  Did the biller even consider appealing?  If there was a reason that the claims were not submitted in the 90 day time frame the claims might be able to be appealed.  (The appeal must be within a certain time too!)

Second, do you have a provider rep for the insurance carrier that this involves?  If you do, I would contact that provider rep and explain what happened.  You did try to do everything you could to make sure the claims were filed timely but your biller let you down.  It is possible the provider rep will do a one time exception and allow the claims to be processed.  Our local BC will sometimes do this for providers who are in situations similar to yours.

Now as far as her advising you that you need to write off the $950, that does seem unfair.  That was a lot of work provided by you that you won't be reimbursed for.  If the reason was simply she didn't submit them in time then she should be responsible.  However, without a contract I don't know if you can do anything about it.  You could ask her if she has E&O but like you said, doubtful.  I hope you have at least made other arrangements for your billing.

I wish you the best in this situation.  Let us know how you make out.

[TN Doc]

Michele,  Thank you for your feedback. 
The biller thought she had a longer deadline, but nonetheless, she shouldn't have held the claims for over 6 months before submitting them.  She checked and there is no appeals process since it was her error.  At this point I have no other choice but to write off this amount against her invoice and write off the balance.  Since there is no contract, I don't see how she could sue me for writing off the payments against her bill.

I was curious what the ethical and legal guidelines for billers are in a situation such as this. I appreciate any feedback.

[Michele]

I personally would still try to appeal.  You directly, not the biller.  They will have no sympathy for her, but they may for you.  It's not a guarantee but you never know.  But the part that blows my mind is how could this person hold claims for 6 months??  Why?  Was there some reason (other than "I thought I had longer")?  Her job is to bill the insurance.  Why would she wait even if she thought she had time?  Not to mention 6 months is actually long, most insurances are 120 days or less!

[rdmoore2003]

I agree with Michelle.  You should write a letter and drop the claims to paper and mail them in with the letter attached.   Now, for the biller, she would have found her last paycheck as she was out the door.  As for now, it is $950 that you know about.   It may be worth it for you to get someone to do an audit of your claims.
Depending on your software, you may be able to run a report on services that have not bill filed, however, if your biller has not put the charges in, then this will not work.
Does your biller do in-house billing?

[kristin]

I am with everyone else in that I think you personally should still try to get the claims paid, by contacting your provider reps for each insurance involved(hopefully it is only one insurance, that will make it easier), and explaining the situation, to see if they will let you file anyways.

There was a time when there was no recourse when it came to timely filing, but in the last few years, I have seen some insurances work with providers when situations that are unusual like this happen.

[TN Doc]

Thank you all for your feedback.  I plan to file an appeal and speak with the provider rep again to see if there is an exception.  She is the one that stated there was no appeal process if it was the fault of the provider or biller.  I will have my new biller look in to the old claims to see what else is missing.   

 I have always done my own billing for this very reason, but decided that my time was better spent helping patients. Unfortunately, I have spent more time chasing her, checking over her work and  I'm out almost $1,000.

I just needed the feedback from the billers' perspective that she should be responsible and she should not simply shrug it off. She didn't even apologize. She is blaming me because I didn't tell her that there was a 90 day limit, depsite her 30 year history as a biller.

 I appreciate the support and feedback!

[Michele]

I am trying to be professional since we are not hearing her side, however it is very difficult!  She gives outsourcing a bad name.  We file ALL claims given to us within 3 business days of receipt, unless we didn't receive all information needed to file the claim.  In that case we notify the provider's office what we need.  I believe most billers follow a similar policy.  It is absolutely INEXCUSABLE for her to try to blame you as the provider for not telling her about a 90 day filing limit.  There are so many things wrong with that logic.  First of all as a biller she should know the filing limit, and second of all the claims should have been filed once she got all the information REGARDLESS of how long the filing limit was.  Who in their right mind would wait until just before a filing limit to file anyway!  Oh my GOODNESS!  I am so sorry you have had such an unpleasant experience.  We are not all that irresponsible. 

[Michele]

OK, I'm not done yet.  Who in their right mind thinks it's ok to make a provider wait 90 days to get payment for their services!  Seriously?  My providers would have been all over me within 3 weeks of not getting any checks.  Providers have bills to pay, families to take care of, etc.  That is just so unbelievable.  This one belongs in one of our books!

[kristin]

Michele, I am equally as aghast as you are about this whole thing. I have never heard of a biller, in house or out, who waits 6 months or even 1 month to file claims. And they all know the timely filing periods for each insurance they are dealing with, because that is one of the most basic things you should know as a biller, as far as I am concerned. Add to that the volume we are talking about here...under $1000. It isn't like she was being asked to bill $100,000  worth of charges. I would guess most of us could bill $1000 worth of charges in less than an hour. We may not have her side of the story, but I just can't see any side that would not make her seem lazy/inept.

[Michele]

Agreed!

[rdmoore2003]

I am seriously worried about the fact this "biller" has 30 years experience and did this.  My gut tells me that this provider is going to find out down the road that it is more than $1000.   I so hope my gut is wrong since I am in need of a snack.  I hope this provider is having better luck with the new biller.

[Michele]

Another scary thing is that she came "highly recommended by a colleague".  How much money has that provider lost?

[kristin]

You are both mentioning things that crossed my mind. How much more damage is yet to be discovered, and how can someone be highly recommended, yet be so inept? Situations like this drive me crazy, because I take my job(s) as a biller very seriously, and it just chaps my you-know-what when I see someone like this who doesn't.

That said, I hope any doctors who may be reading this forum take a lesson from this...no matter how good a word of mouth referral is, do your homework before hiring someone to handle your billing, and make sure that person is actually qualified to do it.

[Michele]

and it just chaps my you-know-what when I see someone like this who doesn't.

The crazy part is not only doesn't she take it seriously she actually doesn't even take ownership of the lousy job she did for this provider.  There are so many things that are just jaw dropping!