Texas Tech Physicians, along with all other medical practices, deals with the issue of medical claims being denied for payment by insurance because they were not initially filed in a timely manner. This is a challenge that is not helped by the fact that each insurance carrier has its own guidelines regarding the deadline for filing claims. Some that we deal with are as short as 30 days and some can be as long as one year. Overall, our performance on getting claims filed in a timely manner is “within normal limits”—but, of course, all of us would like to see our practice at “best practice” level when compared to others of similar size and kind.

What are some reasons why a claim falls outside the allowable time frame or is otherwise denied?

• We mess up.  We simply don’t get the chart completed, coded and sent to the payer in time. On this one, we really have no one to blame but ourselves. These instances hurt because we don’t like to treat a patient and have his or her insurance obligated and willing to pay us, but then be denied simply because we didn’t send the bill. Ouch!

• We get tangled up. Sometimes claims are filed in a timely manner, but not received by the insurance carrier. Bills go through a clearinghouse. We use GE Centricity. Their electronic data exchange (EDI) services link us electronically to most payers for the processing of claims and electronic remittance advice. They use screens or filters, if you will, that a claim must pass through before the clearinghouse will send the claim to the ultimate payer. If a claim doesn’t pass through the filter, it is sent back to us to remedy. The clock is running, so we only have so much time to “get it done” before it becomes a stale claim.

• We make small mistakes that delay filing. Other times, claims are denied for timely filing when they were not filed within the timely filing period due to initial mistakes, such as incorrect information. This may be due to a variety of things such as a typo on our part, it may be that the patient offered the wrong insurance card in a clinic, and we ended up with the wrong financial status classification (FSC).  Or, it may be that when the medical coding was done, it was done incorrectly. Lots of things can go wrong.

• We are denied. Sometimes a payer will just refuse to pay a claim even if it was submitted in a timely manner. This is rare, but payers, just as providers like us, are not perfect. A cynic would say they “try to get by with it.” I really don’t think there is a scheme among the major reputable payers to not pay as if in some John Grisham novel. But, we do have to be on the lookout for such mistakes or oversights. Generally, if that happens, one letter to the Texas Department of Insurance will resolve the matter in short order. Again, we have to be alert enough to catch it.

If a claim was denied for timely filing, it is difficult to appeal. However, there are circumstances in which it is worth the effort if there is at least a chance of getting paid. There must be a logical reason as to why it wasn’t filed in time. An example is we receive a confirmation number back from the payer that they received the claim, but they can’t find it in their system, and the claim is then resubmitted after the filing deadline. This would be worth working on to collect payment. Basically, if we believe we have an explainable and valid reason that the claim was not submitted in time--we can submit an appeal. Excuses such as “we were short handed during that time” do not meet aforementioned criterion.

Bottom line

It is important to file claims as quickly as possible. There are always things that come up that cause delays and timely filing denials do happen. It doesn’t mean that we accept it or feel good about the situation. I play golf. When I mess up on one hole, I certainly don’t like it, but there is always the next hole on which to do better. Learn from mistakes, try to minimize them and go on.