Timely Filing for Claims and Appeals | Medical Billing Tips

Well, as I said before, this is a question that comes up all the time in coding, billing and practice management courses that I work with. So I just thought I'd go over it one more time for students that had never heard me talk about it before. And it's to explain the filing limits with the insurance claims for the initial claim as well as the appeal process. So basically we'll be covering information about how all insurance companies do enforce filing limits for both their initial claim submission as well as for appealing claims. So you really need to know your payer filing limits and create a cheat sheet for your demographic area. And when filing or appealing a claim you want to be absolutely sure that you get those claims in early because there are always technical problems or if you're using snail mail, things get lost in the mail and and it happens more often than not. So if a doctor gives you a charge today and expects you to transmit it tonight and thinks that it's going to be okay because the cutoff's tomorrow, I can bet you that it didn't go through for some reason. There's always a delay. And insurance companies do look for specific proof of when they received it in order for you to get paid. So you want to pay also attention to notifications of changes regarding time constraints, features, years. We were dealing with a year and a half with Medicare and then they changed to one year of submission. So pay attention to any of your payers notifications because they will send them to you via email if you sign up on their website. Lastly, when you do your aging, the follow up, I can't say it enough, just pay attention to your follow up because you can see trends there as far as claims not being paid and you can see well gee, if this whole bunch didn't get paid there might be a problem and so forth filing limit I can't stress enough. Below is an example of how this particular payer, which is TRICARE, allows 90 days from the date of service to bill out a claim. But the biller really has to know all the filing rules. So in this particular case you could move it up just a little bit. Lorraine we see at the top that the date of the notice when the doctor got paid was 05-15-2006. And below where the other red arrow is, it shows date of service 04-08-2006 and it was paid. So it clearly is showing me that the biller had the work and transmitted it right away and tricare paid it. But what I do want to point out is that if for any reason this Claim denied or there was any type of an issue with it. And if you were appealing to TRICARE, you would have 90 days to appeal from the date that the explanation of benefit was dated. So you're not going to go 90 days from the date of service, but from the actual notice or EOB. So the May 15th you attack on 90 days. And if it's a secondary insurance, it might be 60 days, it could be a year. And whatever it is, you have that amount of time from the date of the original either payment or denial of an eob. Now what I did, just so that you all understand is that Google is a wonderful thing and I just wanted to point out how when you know when you're working for a practice, what payers you're dealing with, whether it's California or Massachusetts, go into those payer websites. So for this example with tricare, because I showed you that explanation of benefits, I just happened to find these guidelines and they were current. And it basically said that TRICARE network providers must file all claims within 90 days of the date of service. Where TRICARE is the secondary payer, the 90 days would begin after the first initial claim paid. So if Medicare was primary and they paid today's date, you would have 90 days from today's date to bill out TRICARE. And if TRICARE denied, you would have 90 days from this denial to appeal. Okay, next one. Oh, and also non network providers may file claims up to one year after the date of service and that really is up to the biller to find out because a lot of doctors that are in networks with particular payers, they're usually affiliated with hospitals that are either involved in the network or not. So only you will know best. And that's why I really stress you have to check it out. Now another example here, just to show you very quickly, is the basic claims processing times and different guidelines. With TRICARE, most clean claims will process within 30 days. And generally if a clean claim goes over the 30 days, they will pay you interest. That's pretty standard with most insurances. And then they give you the criteria for clean claims, basically complying with the billing guidelines and requirements, having no defects or improprieties on the claim, including documentation if it's applicable. Okay, and move up a little more. Oops. Yeah, and also do not require special processing that will prevent timely payment. If you have any problems with your EOBs, whether you don't think they paid enough or anything. Tricare gives you a website that you can register and you get a username and Password and you can access all your doctor's information, or you can call voice recognition and call a number and speak to someone. So that's just telling you a little bit more about how to process a claim. Okay, next page. What I did is just showed you an example. There are multiple contractors that process Medicare claims in my area and in other areas in the United States. NGS is one of the contractors. What I wanted to do is just show you that not only do they give you information about when you have to file, how many days you have, but if you look here, it gives you all the information on how to appeal a claim. If you look to the left, it will say who can appeal a claim, level of appeals, and the time limits for filing. And it even explains a reopening and a redetermination. A reopening is very basic. You messed up on a diagnosis code, you forgot a modifier, Something very basic. Redetermination. You may feel that a surgical procedure that's not typically bundled into another procedure should have been paid or something. And it gives you all the guidelines. And if you look to the right of this, you'll see there's an appeals timeline calculator, which I'll show you next, as well as appeal forms. And that is with any Medicare website and pretty much every other insurance company. It may look different, but the information is the same. Now, the next page has to do with just basically the appeals calculator. Here we are again. I won't go into big detail, but you have your option of picking if it's a reopening redetermination, and it tells you the amount of days that you have to appeal, like 120 days or whatever. And again, all your carriers will give you this information. And this is just an example of what's available on the websites. The next one is just a very simple explanation of what a redetermination is. And it's just giving you the filing limits again, how many days, time limit to initiate a redetermination, you have 120 days from the date of the receipt of the initial determination, which is the eob. Then once they come up with the determination, if you you're not happy with it, you have 60 days to apply again. And it just gives you more information. It also tells you a little bit below on this page that you should submit your redeterminations online, but you can do them on mail. And then the next page you'll actually see a copy of a form. Just as an example, I won't go through it, but it's basically the beneficiary's name, ID number, the reason why you're appealing, and so forth. Tameka had a question. She said, does timely filing policies apply even if you're not contracted with the payer? Yes, yes, they do. And I've had first hand experience with that, so yes. And then another related question. Do coders or billers process claims? It really depends. In my billing service, all the billers always coded or made sure the coding was appropriate and then they billed it out. And when you're in a big group practice management within a hospital setting, usually all those roles are broken down. So a coder would actually be coding, but the biller is really, they'll have one that registers, one that does key punching, one that does coding, one that does payment posting, and one that does problem resolution. My mindset is I like to do it all because oftentimes the left hand doesn't know what the right hand is doing. And I like to have control when I used to bill all the time of knowing when my claims went out and that I was responsible to leave notes against a patient's account. But typically the coders don't have anything to do with the appeals process unless there's an issue with the code, that the biller may approach the coder. But that's why a lot of billers are already coders, because you will find out fast enough that you have to understand coding to a certain extent in order to understand why some of the claims are denied. Then we had one more charity wants to know if Medicare does not pay a clean claim within 30 to 46 days, what would you suggest doing at that point to get them to pay the interest? I've never run into a time where they haven't paid the interest. But sometimes, depending when we went through ICD10 or major changes, where we anticipate and they tell us ahead of time that there will be delays, I'm not sure if we've seen interest on that, but a typical delay in payment, I've always seen the interest given to the doctor. But again, if they haven't been paid, first of all, you want to make absolutely sure that they're even in the system. And so you can check online one or two just to make sure they're there. Because if they're not there and you have a whole list of Medicare claims sitting there, then something may have happened between your office and the clearinghouse or the clearinghouse and the payer. And that's where I really stress the follow up and staying on top of your work because the filing limits really do come into play and they're not as lenient as they were even a year ago. They're so strict. So you want to make sure that you understand that. Now this is an example from another Medicare provider, and this is Palmetto gba. And just where the red arrow is is all I'm going to point to that Medicare claims for which assignment was accepted must be filed within one year from the date of service. And that's just telling you you have one year to file that claim. And all the information I showed you prior to for appeals and redetermination. You can also find this on the Palme GBA Medicare website. Matter of fact, this is my favorite website. I love this contractor. I wish we had them, but they're very clean cut their instructions very clear. There's nothing left unanswered. But the information, as you can see, is right there in front of you from any website. Now the next slide is a cheat sheet. And whatever you do, do not go by my numbers. This is strictly an example. All right? But this is what my staff always had and I used to have. In the day I would list all my key insurance companies, Medicare, Blue Cross, Blue Shield, hmo, ppo, Medicare Advantage, one of their plans, Tufts Medicare Preferred. And as you can see, the initial claims varied at one point. Blue cross, Blue Shield, HMOs, we only had 90 days, but their PPOs and indemnities, we had a year. Now everything is 90 days. Their appeals vary from 90 days to 120 days. One hundred and eighty days, you really have to go into the insurance companies that your providers are contracted with if you have any plans. And I know in Massachusetts we have a few that are 60 days, you stay on those because by the time you get it and it's transmitted and you get your EOB back, if you get it back, you don't have a whole lot of time to play there. So those 60 days, make those a priority and very quickly. You just want to allow time for technical problems. I would never submit a claim one to five days prior to the filing limit. Clearinghouses payers have maintenance downtimes where no work is transmitted. Databases crash, whether it's your software, the clearinghouse or the insurance companies. Regardless of when you transmit, if the payers consider when the claim was received, it doesn't matter if you sent it one day before if there was a delay. And trust me, there's plenty of them. Things get lost in cyberspace or there's problems claim will be delivered late and they'll deny it over the filing limit. So billers oftentimes can appeal. But like I said, it's very rare that they pay. They don't have the insurance doesn't have an electronic acknowledgement saying that they have that claim. They don't usually work with you. As far as problems where your claim is denied and you have to file, you have to first ask yourself, was it the front desk? Was it the patient's fault? If the patient gave the information but the front desk was negligent, then the practice is liable if we didn't get the information on time. So you can't bill the patient. But if the patient came in and did not give updated information and billing company's office will call the patient will try to get the office to call the patient and they finally get around to calling you four months after four bills have gone out, they're liable. But again, your office should develop a protocol and stick to it for all your filing limit scenarios because front desk sometimes doesn't update their files by the time the biller gets the work. And that's a bad practice to get into. And follow up of claims is imperative. Problems will jump out when you examine the dates of the outstanding claims. And a lot of times you'll see that your transmissions, even though they said they were sent, weren't. So that'll keep you in line as well. And basically in summary, just know your clean claim submission filing limits as well as the filing limits for your claim appeals. Use designated payer forms, phone calls, or online access to appeal your claims. Definitely use a cheat sheet for the initial and appeal file limits. Allow time for technical problems and delays, and file clean and appeal claims as soon as possible. Don't let them sit there and monitor your aging to see if any claims are old. Don't allow this to occur after the filing limit because it's really tough to get that money. And if you're billing or coding for a surgeon that's not $50, you may be talking $2,500 and they won't be happy with you. So that's.