Billing > Billing
Late Filing Appeal
Michele:
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.
Michele
PMRNC:
--- 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!!
--- End quote ---
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.
PMRNC:
--- 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.
--- End quote ---
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.
Pay_My_Claims:
--- Quote from: PMRNC on April 05, 2010, 11:55:46 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.
--- End quote ---
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.
--- End quote ---
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:
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.
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