Billing > Billing
Late Filing Appeal
oneround:
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.
PMRNC:
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.
Pay_My_Claims:
--- Quote from: PMRNC on April 05, 2010, 10:35:51 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.
--- End quote ---
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....
???
PMRNC:
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?
Pay_My_Claims:
--- Quote from: PMRNC on April 05, 2010, 09:09:51 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?
--- End 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!!
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