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
That's sad that claims are paid that way. It shouldn't be at the "discretion" of an adjuster.
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.
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?