MEDICAL BILLING FIGHTING TIMELY DENIALS
Know your state’s law on timely filing limitations. Also, you should know the time limits for all carriers in which your doctor/client participates with. The contract for participation will define timely limitations.
Example from BCBS of Arizona: BCBSAZ asks providers to submit complete and accurate claims, preferably within 30 days of service, and require submission within one year of the date of service. BCBSAZ will deny any claims received more than one year after the date of service. Members are not liable to a BCBSAZ contracted provider for payment of a claim on which BCBSAZ denied payment for lack of timely filing. For the Federal Employee Program (FEP), the claim submission deadline is December 31 of the year immediately following the year in which service was rendered.
For paper claims – always send certified/return receipt so you have proof the claims were received. You can use the return receipt for proof that the claim was received timely.
For faxed claims – always ensure that your machine prints out a “faxed received” message you can use as proof that the intended party in fact did receive your fax.
For electronic claims – use your clearinghouse submission report as proof a claim was submitted timely. Some carriers will accept a “print screen” printout of the filed date from your billing software program.
Non-participating Payer Denial
The Benefit Argument – this argument is one you can use to appeal to the carrier by framing it as 1) we are not obligated to file claims on behalf of your insured. 2) Your insured purchased health insurance in good faith and this is a covered benefit they are entitled to receive benefits for. In the above example (BCBS AZ) the patient would have had up to a year, so you could throw that date out since the provider isn’t obligated to file a claim for non-participating (excluding Medicare) carriers.
ERISA
And finally, ERISA can be your best defense. Under ERISA, state law has no jurisdiction, and neither do plan limitations. See 29 USC 18, 1003(a) and 1144(a) http://codes.lp.findlaw.com/uscode/29/18/I/B/5/1144 and US Supreme Court Decision in Davilla vs. Aetna and Calad vs. Cigna for references. Note that you must have the patient’s written permission to pursue an ERISA violation/denial unless the patient is willing to pursue denial him/herself.
For more information on Vitruvian MedPro’s HIPAA Compliance kit visit: HIPAA Compliance Kit.
At Vitruvian MedPro, a Massachusetts based medical billing and practice management consulting company, we help medical practices improve cash flow and focus on patient care by providing medical billing, medical coding, and patient collection services. Visit our web site at Vitruvian MedPro