Billing > Billing

Timely Filing for Patient?

<< < (2/3) > >>

dfranklin:
Thank you very much for the feedback!

Steve Verno CMBS, CEMCS:
Timely filing is under the juridistimction of
1.  State Laws.
2. Federal Laws.
3.  Provider Contracts
4.  Patient benefit contracts.

1.  State Laws:
some states do have timely filing limits. For example, in Florida you have  FS 641.3155 and 627.6131, both state the provider has 6 months from the date of service AND from the date when the provider receives the correct insurance information.  For Medicaid, in Florid, you have one year.

2.  Federal laws:
Federal has juridiction over Medicare, ERISA, and Federal Employees.  Medicare usually has a 15 month timelimit.

3.  Provider Contracts. 
As billers we need to know the contracts our provider has signed.  The timelimit that is listed in the contract may supersede current laws.  Instead of a 6 month or 15 month timeframe, the provider agreed to accept a 90 day time limit which is the usual timeframe in most provider contracts.

4.  Patient Contracts

This is the contract the patient has with the insurance company when the patient obtains health care coverage themselves or it is provided as a benefit of employment. With some patients, the time limit could be 30 days to 90 to 2 years.  To know the pecifics, you need to review the patient's benefit manual or summary plan description.

KNowledge is power.  The more you know, the better ammunition you have to fight back with frivolous timely filing denials. 


I see many e-mail and postings about how a previous biller never sent the claims in a timey manner.  It should be understood that if this happened, the problem wasnt with the insurance company. They were available to receive the claim.  If the time limit has passed, The provide may have to eat the claim because it was his fault for not ensuring that his biller did their job.  The biller represents the provider.  If there is still time to get the claim in, then do so.

PMRNC:
You can save yourself a lot of time and headache by just calling the carrier for their timely filing limit. I doubt you will find a carrier who's limitation is not up to par with state laws. Much easier to call the carrier. One phone call :) 

dfranklin:
To clarify:

My question was not about the laws with timely fiing with the carriers.  Their previous biller screwed up and did not get them in. I have tried to still submit and ask for exceptions etc. But my question was what is the laws (where do I find them) on sending bills to patients for these?  When is it too late to send the bill as patient responsibility to them?  And I see that some are saying if we are past timely filing with the carrier and provider is in network then it is agains the contract to bill the patient? 

This brings a new question: What if we are past the timely filing and it was not biller/providers fault (ie correct insurance info, etc)?  Just curious as to the difference and how to "prove" the case either way....

See the main reason is I am dealing with a chiro and their reimbursement from the carriers is typically minimal and there is a lot of patient responsibility anyway. So just because lets say on a $300 claim we are not getting the $30 dollars or so from the insurance because it was not filed timely, why should the doctor lose the $270 patient responsibility portion? This was going to be billed to the patient anyway....so how long do we have to send patient responsibilty bill to them (legally or contractually)? 

Steve Verno CMBS, CEMCS:
Linda has an excellent idea.  Here in Florida, I did that.  Every insurance company I spoke with said they had a 90 day time limit.  Ive sent claims 7 days after the patient was seen (this is because with emergency medicine, you have to wait for the hospital to send you the copy of charts and patient info)  For example, patient seen on jan 1.  Claim went out to insurance electronically on Jan 8.  The insurance company denied the claim on Feb 15 for not submitting the claim within 90 days of date of service.  When shown Florida has 6 month timeframe, they ignore this until a complaint is sent to the office of insurance regulation.

Every insurance company where Ive negotiated contracts with, want between 45 and 90 days for claim submission, when informed of Florida's time limit, the insurance company responds with, we have our own and every doctor agrees with our timeframe.  Our contracts states claims will be submitted within claim submission timeframe under applicable State or Federal Laws. The insurance company;s dont like it, we tell them if they wish us to be contracted, this is a make it or break it requirement. 

Most State timely filing laws are listed in the insurance laws.

Many insurance contracts I have seen do not allow patient balance billing if the provider failed to submit the claim within the contracted timelimit. 


Our practice policy is, if the patient withholds insurance information until aftr the State time limit to submit the claim, we have the patient pay if the claim is denied.  Howeverk we have been working with our cotracts to close this loophole.  We have language added to state if the patient wilfully withholds correct insurance information until after any and all timely filing limits, we can still submit the claim and the crrier has to pay.  The practice policy is if the billing company screwed up and didnt send the claim in a timely manner, we didnt hold the patient responsible for the screw up. 

A couple of years ago, we had a huge problem with New York Medicaid paients withholding Medicaid info.  They wee treated as uninsured .  The account became delinquent and was sent to our collection agency.  It was whe at collections that the patient revealed Medicaid coverage.  We would get a call from Medicaid telling us we had to write the bill off.  We refused.  I wrote to the Department of Health and Human Services.  CMS responded saying if the patient made a  freedom of choice decision to present themselves as an uninsured or self pay patient, we were entitle to teat them as a self pay patient.  Ive ised that letter to get medicaid and te medicaid HMO to pay the claim even after their timely filing limit

Navigation

[0] Message Index

[#] Next page

[*] Previous page