Medical Denial Claim

Delays become denials – quickly

The American Medical Association has reported that over 17% of all denials of claims are for the simple reason the failure of the physician to file the claim in a timely manner.

The reality is that there is no reason why any claim should be lost to timely denial. If timely filing denials are among one of the reasons your revenue is leaking away, only you can stop it, and there is no reason to allow it to continue.

Unfortunate too often physicians have become victims of the staff excuse of blaming the insurance company for the denials, lumping them all together.  This denial cause, timely filing should not be occurring. To prevent this, however, EHR for small practice have come into play an attempt to streamline workflow and filing but the transition from physical practice to digital forms of administrative work is an impediment to the cause. Furthermore, the misnomer that small practices don’t require EHRs or are too costly creates a further hassle in the filing situation

A claim denied for timely filing is a self-inflicted injury to your income.  It occurs for the simple reason that your practice cannot get a claim “received” by the payer within the payer’s filing deadlines, usually 60 days.  First off it is outrageous that your practice can’t get a bill to the payer in 60 days, and equally outrageous that you are letting your income lag even that long.

The standard in your office must be to bill daily.  No excuses.  Every day the prior day’s claims must be sent out.  In most cases, this means sent electronically.  If paper claims are still being created, mailed daily. Do not allow your office to fall behind, and if it is not the standard practice in your practice to bill daily, then review the processes in your office, find out what the impediments are, and remove them.  Do not allow excuses.  Daily billing needs are the standard.  Ok if you’re a surgical practice and need to get a copy of the surgical report from the hospital to the bill, then billing within 48 hours may be the appropriate standard.  In any case, it is too easy to fall into the trap that your staff is too busy to do daily billing.  What possibly could be more important than getting you’re your earned income?

But you are not done there.  You need to keep an eye on your receivables.  Now that it’s billed, if you are not paid by day 30 from the date sent, you must go to the payer’s website and look up any claim that is still outstanding.  No this is not an overwhelming task.  If your office is billing out daily, most of your bills will be paid within 30 days, especially with daily billing.  This means that day you will have a short list, if any, claims outstanding at 30 days.  Check these on the payer’s website.  If you do not find the claim listed, and its status, then send the claim again.  Electronically or if paper, by certified mail.

The task is to assure that your claim has been received.  Sending is not the goal, receipt by the payer is.  Therefore, by checking at 30 days you are making sure that no claims have gotten lost in the process.

Once you have assured that your claims have been received, if you are not paid within 45 days of receipt, then now with a copy of the proof of receipt, a copy of the electronic receipt, or paper receipt of mailing, your clam cannot be denied for timely filing.  And you are in a position to send a complaint to the state regulatory authority, generally the Department of Health or Insurance in your state.  Nearly all states now have statues that mandate prompt payment form insurance companies.  No reason not to let these tax dollar paid staff help you get paid.

In any case, your proof that the payer has received your claim keeps your claim a legitimate claim against the payer, however, you want to pursue it.  It cannot become lost to timely filing.

Author Bio:

Alex Tate has served in various positions at leading health IT organizations for the past thirteen years. Most recently Mr. Tate served as Vice President at a leading EMR organization. He currently oversees product management and revenue cycle consulting for a number of organizations. Mr. Tate oversaw the development of many emerging products and held leadership roles across health-tech strategy, operations, service organization development, delivery, and optimization. His ongoing collaboration with startups and academic research centers are paving the way for the development and commercialization of groundbreaking technologies like artificial intelligence, augmented reality, HCI and other initiatives for a future that offers the promise of transforming care delivery through cutting-edge technology and progressive methodologies.