Primary vs PI (Timely Filing)

[dfranklin]

Does anyone know if we can file for an appeal asking for an exception for the following (for BCBS):  A PI case was pending and they patient lost the lawsuit so the patient's attorney suggested we submit the claims to their primary insurance (BCBS).  The claims are now old (2008) and past the timely filing limit and have been denied by BCBS for this reason.  Can we submit an appeal stating that this was just settled by the attorney which is why we waited?  If we can how do we go about appealing or asking for the exception in this case?  Or is the provider out of luck?  Should we have been submitting to the Patient's Primary all along? Seems like the patient should be able to get reimbursed from the other party first but since they lost you then go to their primary...

Can anyone clarify this and help direct me?

Thanks!

[PMRNC]

YOU can certainly try, however BCBS, had you submitted to them within the timely filing limit would have put the case on ROR status OR pended them for the outcome of the case.. so there's a fine line.  What I would do is write a letter, include documentation of submission to PI and any documentation that shows the time frame the case was pending. It wouldn't hurt to get a letter from the attorney as well on behalf of their client (Patient).  Technically this will be a "PATIENT appeal" they would be held responsible, but however it would behoove you to attempt to collect reimbursement, I would also make the patient aware of that fact that you are helping them as a courtesy.

[dfranklin]

So are we actually "Appealing" it? Do we right an appeal letter? Or just a letter asking for an exception?

If we would have submitted in the timely filing how would they know about the pending PI claim? Is there something we would be doing or should be doing to let them know about it?

[dfranklin]

On the lettter I meant to ask if it is a "Patient Appeal" do we right the letter stating it is a Patient Appeal we are doing on behalf of the patient or do we as the provider just ask for an exception?

[PMRNC]

I'm sorry, I should have clarified it better.. I would submit the claims with a letter asking for override of the timely filing limit, so it really wouldn't be an appeal. I would state in that letter all the details of the case.. I would NOT submit any further documentation until it comes down to filing an appeal. Sorry, I should have read your first post more clearly, since these were never submitted this would not be an appeal.

[jenfogle]

Will you clarify with regards to the timely filing being patient responsibility?  My experience has been that timely filing denials are provider responsibility.  If the provider is taking the responsibility to bill their pt's insurance, then they are required by contract to submit within timely filing limits.  I don't believe a PI case is any different; the provider should have billed pt's private insurance in order to get the claim on file.  As you stated, they would have either pended or they would have paid the claim and then later go after the attorney for reimbursement.  I really hope I'm not wrong! haha, we've written off many charges after learning the hard way that we should have been billing private ins if it looked like we weren't going to get reimbursed from the PI within timely limits!

[PMRNC]

Well, technically BCBS can still deny..the point is it's not an appeal as there was no denial to appeal..You obviously can't go back.. HAD they submitted to BCBS, they (BCBS) would have requested details and sent the provider a ROR letter which would basically say they will pay claims, however if the suit is won they want their money back..That would have been the proper way to handle it from the beginning..but hindsight is 20/20.. it however isn't a lost cause..you never know, it can't really hurt to try.  I don't believe however the provider is out of luck...it's kind of a sticky situation..the patient would have some liability there too..

[DMK]

JMO, but it the doctor hadn't been paid already, it must have been a no Med Pay or Third Party Claim and there should have been some sort of "agree to pay" signed by the patient and/or their attorney. 

Our office no longer takes Third Party claims for just this reason.  We just bill the patient's health insurance or they pay the cash rate per visit.  Then let the insurance companies duke it out.  Now, not only is the patient out of luck, the doctor may be too.  Sorry that happened, but sometimes the cases aren't so great.

If it's a Med Pay case, we bill the Med Pay first, then if it runs out (because it's low, or the patient had significant injuries) we then bill their health insurance.

We are finding more and more that the attorneys are insisting that the patient use their health insurance 1st to get the discounted rate.