Coding > Coding

New client - very old A/R

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PMRNC:
The claims you want to appeal, of course if they are claims that can be appealed you should attempt it. For those never submitted, I always say, what have you got to lose? If you are taking on the project alone of cleaning up A/R I recommend you are reimbursed on an hourly rate rather than a percentage. This way you are reimbursed for the time and work you put in regardless of the outcome. For timely filing, no, billing negligence is never going to fly as an appeal, your best bet is to go with an "oops, we are sorry, we bad, could you please consider the claims"  I used to be a claims examiner and really it depended on the claims, the appeal letter and even if I was having a good day or bad day.. sorry but that's true. Examiners at all carriers have authority and payment threshold's they are allowed to use to make administrative decisions. Late/Timely filing guidelines are include, I can't tell you it will work, can only tell you how I reviewed them when I received them. I first looked to see how many there were, then I look at the appeal letter and then I just make a decision and basically it boils down to whether I think there should be an exception made. Not exactly what we want to hear as billers but still doing nothing insures NO reimbursement so again, what do you have to lose. I can make a suggestion, if you have a LOT of claims totaling a LOT of money, I would call the carrier and see if you can get a specific examiner on the line that will allow you to send them to him/her, document the phone call and include it with your appeal.. this way you give someone there a heads up. Above all be super nice.. you catch more flys with honey than vinegar my mom always said :)  Treat your examiner as you should treat your waitress :) LOL   By calling ahead, you are making a good conscious effort to correct a "mistake" and you are more likely to gain the sympathy and understanding of a good claims specialist by calling ahead.    JMHO.

aboudreau:
Linda, that is very good advice. Would it be a claims rep I try to talk to? Is that the same as an examiner or is there a different department I should be looking for?

Thanks!!

PMRNC:
It depends on the carrier, with some you have to speak only with customer service and they make the decision to contact the claims department. It also depends on how the carrier is structured. Some examiners simply work on specific employers and some carriers have other means of determining which policies they work on. If I need to speak to a claims rep I usually call the claims line and request to speak with an actual claims specialist. Some will let you and others will not but if the plan does have a specific examiner they will give you their name at the very least. Some carriers will have their customer service lines ring right to the examiners.    There's a few plans I work with who are great and I have a few specific contacts with many of the carriers. Comes in handy :)

Michele:
We have contacted provider reps in the past and many times they will allow us to submit ALL claims affected at one time with an appeal and they make an exception.  Like Linda said, it's worth a try.

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