Timely Filing Denials

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Every day, I see people asking questions about how their claim was denied due to timely filing reasons and the person asking wants to know if there is a modifier, or another CPT code that can be used to overturn the denial. From a personal perspective, with some insurance companies, a timely filing denial is a nuisance denial. There should be no reason to deny a claim for timely filing. Why? Well, the doctor performed a service that is a benefit that the patient is entitled to receive. The medical record is available to be reviewed to provide foundation that the patient received the service. The patient is paying the insurance company to pay their claims if the service is a benefit they are entitled to receive. Therefore, why shouldn't the insurance company pay for the service?

Although timely filing limits can be a nuisance, I can see why they are necessary because, after all, why should an insurance company wait forever to have a claim sent to them. Insurance companies must understand that doctors do not want to hold onto a claim because to do so decreases practice revenue. It behooves a provider to send a claim immediately after the patient was seen. With some practices this is not possible. For example, Emergency Care providers send claims about 2-3 weeks after the patient was seen. This is because the medical record must be sent to a coding/billing company for processing. The practice is also dependent on the information sent to them by the hospital. Some providers do withhold claims as a means of allowing any patient deductibles to be met so that when their claim is sent, it will be paid rather than be applied to the patient's deductible.

Timely filing has several factors. One is the contract between the patient and their insurance company. Another is the contract between the provider and the insurance company. The third is State or Federal law. When looking at different patient contracts, benefit manuals or Summary Plan Descriptions, the time limit to submit a claim can be from ninety days from the date of service up to one year from the date when seen or discharged. When a provider is not contracted with the patient health insurance, the time limits are per the patient's contract and then it is usually the patient's responsibility to submit their own claim. When a provider signs a contract with the health insurance company, most time limits for claims submissions are usually ninety days from the date of service. State law is very important to know when it comes to filing times. For example, Florida's laws, specifically FS §627.6131 and §641.3155 states that a claim must be submitted within 6 months from the date of service and when the provider receives the correct insurance information. If the claim is based on an auto accident, FS§627.736 requires the claim to be submitted within 35 days of the postmark of the statement.

Providers should incorporate State law requirements in the development of insurance contracts. In additions, exceptions to the timely filing limits should be added as a protection to the provider. These exceptions are:

1. The patient does not provide any health insurance at the time of service until after the timely filing limits or after their account went to the provider's debt collection agency. These types of patients should be treated as an uninsured patient because they are making a freedom of choice decision to be an uninsured patient. The insurance company is overjoyed when the patient withholds the information because when the patient does relinquish the information, the carrier can deny the claim as being timely and they demand the provider write off the bill. You should demand that if the patient withholds insurance information beyond the timely filing limits and you submit the claim, they are obligated to pay for the claim, with interest. After all, it is their member that cause the claim to be sent late.
2. The patient provides incorrect insurance information. Many practices do not verify information provided to them, so the claim is sent to an insurance company where the patient terminated or was terminated. The claim can take months to process and then when the claim is denied, you bill the patient only to have the patient wait months to give you the correct information. Once you receive the correct information, you send the claim with the denial from the original insurance company but the insurance company denies for timely filing. The clause in your contract requires the correct insurance company to pay if the services rendered are a covered service.
3. The patient provides incorrect insurance information but the incorrect insurance company pays the claim. Normally months or years later, you get a refund demand stating that the patient was not their insured. They may have been at one time but their system did not catch up with the claim. Again, you bill the patient and months later they give you the correct insurance information because now their account is at your debt collection agency and they think that by giving you the correct insurance, you will remove all references to a bad debt. Your contract should specify that if the service rendered is a covered service, the claim is to be paid.
4. The patient gives you insurance information, you verify that services are available and the claim is paid. Months or years later, the insurance company comes back and says that the patient has insurance that is actually primary. You demand that the insurance company provide foundation to this claim. Once they do, you contact the other insurance company and verify benefits. You send them the claim with the letter and proof from the other insurance company. The new primary carrier should pay the claim because it was not your fault the other insurance company made a mistake and the patient failed to tell you of other insurance coverage.
5. You verify coverage and coverage is available. You send the claim but the claim isn't paid. You contact the insurance company and they tell you the claim is not on file, so you resubmit it. Again, the claim is not on file, or the claim is on file and you receive a denial that the second claim you sent is a duplicate claim. If it is a duplicate claim, what happened to the original claim? When you call, it is still not on file, and so is the claim that was denied as a duplicate claim. It seems that no matter what you do, the only claim that arrives at the insurance company is the claim that is past their timely filing limits. The one question that no one can answer is, what happens to all of the claims we send. We have the correct address, or we have the correct NEIC numbers. If we send claims electronically, we usually get a confirmation report showing the claims were sent and received. Claims sent by mail are rarely returned as a mail return. When we submit proof of timely filing, the insurance company will not accept it. They only want something from the post office showing the claim was submitted. This is just a stall tactic to keep from paying the claim. Have your contract specify that when the claim is mailed, it is deemed to have been submitted when the claim has the correct insurance address, with the correct postage, and placed into the hands of the U.S. Postal Service. Proof of timely filing that is acceptable, will be a report, created by your billing software, showing the date when the claim was created.

Several years ago, I personally visited a major insurance company and brought with me all of the outstanding claims. They were given directly to the medical director. The doctor gave them to one of the employees with instructions to take them to the claims department. When we ended our meeting, we left the room and saw that the claims I brought were thrown into a trash can outside of the meeting room.

Your contracts should also address issues when the insurance company is secondary to another insurance company. There should be a timely filing limit for secondary claims with the above clauses in the event the patient never gave you any secondary insurance information, incorrect insurance information or you sent the claim and was not on file.

If the carrier has a Medicaid or Medicare HMO product, you should incorporate the same time limits that Medicare and Medicaid allow. Most only want a 90 day timeframe, but if Medicare allows you 15 months and Medicaid allows one year, then as a Medicare or Medicaid HMO claim, you are entitled to the same timeframes.

Timely filing limits should not restrict a provider from having a valid claim paid. Everyone must understand that there are going to be mitigating circumstances when a claim cannot be submitted in a specified timeframe. This is why there are always exceptions to the rule. Providers should be vigilant in ensuring that the claim is verified and the claim is submitted timely. If claims are submitted electronically, the provider should be receiving a report showing receipt of the claim. If a number of claims are to be submitted by paper, then sending them by delivery confirmation may be the best method of providing proof of timely filing. Include a roster with the claims to show what claims were submitted. Providers should also ensure that any billing agent used is submitting claims in a timely manner. Just as doctors should not be held hostage, insurance companies should not be held liable due to mistakes made by providers or billing agents. Both providers and insurance companies should work together to eliminate any problems that should arise due to a timely filing issue.

New Free CMS Web Navigation Resource for Medicare Providers

CMS has just made available a useful resource to help you navigate the recently redesigned Medicare Website. The new CMS Website Wheel provides up-to-date web addresses for the most frequently-used Medicare provider web pages, including the new URLs that resulted from the CMS Website redesign. You can request a copy of the CMS Website Wheel, free of charge, by going to the Medicare Learning Network's product ordering page at http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=5.

Scroll down to the "Informational Resources Category" and select the "NEW CMS Website Wheel." If you have not already registered before, you will need to fill-out an informational form to register with the site and complete your order. The item will be shipped to you free of charge.

PMI's Las Vegas Conference to present a full-range of physician and staff topics

Take two days this fall to better equip your practice with advanced coding and billing techniques, compliance strategies, and health care finance principles to keep your practice in top form. Join PMI in Las Vegas November 9 and 10 for The 2006 Medical Practice Coding and Compliance Summit. This two-day conference will provide you with the latest tips and tools from leading experts in practice management.

Combat rising costs and reduced profitability. Train your team to find every dollar your practice is entitled to. We will have 10 of the nation's leading practice management experts on hand to share coding and reimbursement tips and strategies for improving practice operations.

Attend four general sessions, and create your own learning track with up to seven breakout sessions of your choice. Choose from more than 20 topics covering coding, collections, compliance, financial and legal aspects of practice administration.

These sessions will motivate your key staff, making them more productive and confident in their interactions with patients, payers, and business associates. Your team will be better equipped to handle complicated reimbursement and compliance issues for your practice.

Clinical and administrative staff will return to the practice prepared to guard the practice against risks and improve revenue. Office managers, coding and reimbursement staff, will all benefit from instruction on the latest coding and regulatory updates and money saving tips that will improve profitability and productivity.

Best of all: PMI-certified professionals earn all 12 of the required CEUs needed for 2007 certification renewal!

Save $100 when you register before August 31. Visit http://www.thecmcgroup.net/2006summit.html or call 800-259-5562 for more information.

The Facts About Consultations
"What You Need To Know"

With consultations continuing to be investigated by the Office of Inspector General (OIG), it's time once again to take a look at the process and understanding for what a consultation is, how to code for one, and receive proper reimbursement.

According to an OIG report released in March of 2006, Medicare allowed $3.3 billion for consultations in 2001. The Current Procedural Terminology (CPT) defines a consultation as "A type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source."

A consultation differs from similar evaluation and management services in that a consultation involves a specific request for help with a particular diagnosis or course of treatment on a limited basis, while an office or inpatient visit lacks such a request and can involve ongoing care of a patient. The CPT defines four types of consultation: (1) office or other outpatient, (2) initial inpatient, (3) follow-up inpatient (removed for 2007), and (4) confirmatory (also called a second opinion, Please note these have been removed from the CPT manual for 2007).

Within each type, three or five levels of complexity exist, with a distinct billing code for each level. The level depends on three key components: (1) the extent of the patient history taken, (2) the thoroughness of the physical examination, and (3) the complexity of the consultant's medical decision making.

Pursuant to 42 CFR § 411.351 and section 15506 of the Medicare Carriers Manual, Medicare allows reimbursement for consultations if (1) a physician requests the consultation, (2) the request and need for the consultation are documented in the patient's medical record, and (3) the consultant furnishes a written report to the referring physician. Other provisions of Federal law require that physicians document all Medicare services and bill them with the correct code.

Medicare allowed approximately $1.1 billion more in 2001 than it should have for services that were billed as consultations. Approximately 75 percent of services billed as consultations and allowed by Medicare in 2001 did not meet all applicable program requirements, resulting in $1.1 billion in improper payments. Services billed as consultations often did not meet Medicare's definition of a consultation (19 percent - $191 million), were billed as the wrong type or level of consultation (47 percent-$613 million), or were not substantiated by documentation (9 percent-$260 million).

Consultations billed at the highest billing level (the most complex services, which generate the highest reimbursements under the physician fee schedule) and follow-up inpatient consultations were particularly problematic; approximately 95 percent of each was miscoded. Based on these findings it is highly likely the carriers are going to begin the performance of audits for more recent years. Do not be surprised if payments for consultations you are billing for start to be denied pending proper documentation to substantiate the services claimed.

Providers must take proactive steps in protecting themselves prior to an audit being performed by your carrier(s). I tell all of my clients as well as groups that I lecture for "The best defense is a strong offense." Solicit the assistance of an expert trained in Evaluation and Management Services as well as CMS audits and methodologies.

Knowing in advance can allow you to correct the problem(s) prior to a carrier audit. Don't think it won't or can't happen to your practice. No one is immune!

For more information on the OIG Audit Results and the CMS letter from Mr. Mark B. McClellan, MD, PhD. to Daniel R. Levinson/ Inspector General, or to find out how The CMC Group, LLC can provide your group with audit and consulting services please contact Sean M. Weiss at sean.weiss@thecmcgroup.net or (888) 262-8354 ext. 402.

Managing When the Stress Doesn't Go Away

In recent years, Federal Government employees in several parts of the country have had to cope with rebuilding their homes and lives after a disaster while taking on new roles and responsibilities to help the community's recovery. Disasters are not the only source of long term stress that our employees may face. Threats of violence, whether from terrorism or street crime, can lead to severe stress situations which go on for weeks, and affect many people. Harassment campaigns directed against employees can be nerve wracking even when there is no apparent physical danger. The prospect of losing a group member to a slowly debilitating illness can produce a long period of stress for everyone involved. Organizational change can produce severe stress if employees feel uncertain and worried for long periods.

Getting the job done and taking care of employees under conditions of severe, long lasting stress can be one of the most difficult challenges a manager may face. It's not easy to take charge, develop innovative approaches, and be sensitive to the needs of others when you're at least as uncomfortable as your subordinates. There are, however, some management approaches that have proved helpful in these situations:

Take steps to reduce the sources of stress. If danger is a problem, call the right law enforcement authorities immediately, and get all the advice and concrete support you can for them. If employees are overwhelmed by competing demands in the aftermath of a large scale emergency, set clear priorities and make sure they are consistently followed. You probably cannot "fix" the entire situation, but you can improve it. Your employees will feel better if they know you are working on their behalf.

Communicate with your employees. This is always important, but even more so when everyone is under long term stress. In most stressful situations, one source of anxiety is a sense of being out of control. Your employees will feel better if they have up-to-date information and permission to approach you with their questions. Depending on circumstances, you may want to adopt new communications strategies, such as having frequent meetings, publishing an informal newsletter, and keeping an updated notice board in a central place.

Encourage teamwork and cooperation. Under long term stress, there is no substitute for a supportive, caring work group. Employees will find the situation, whatever it is, less painful if they are surrounded by co-workers who care about them, and will listen if they need to talk, or lend a hand if they need help. A group accustomed to teamwork rather than internal competition will usually be able to cover for members who are temporarily unable to function at 100% effectiveness.

Ideally, your group has always been strong and cohesive. If not, do what you can to help it pull together under stress. Encourage and validate teamwork and cooperation. Avoid any appearance of favoritism and make it clear that there is opportunity for everyone to achieve and receive recognition.

Set clear work standards. Doing good work is always essential, but even more so in times of high stress, since success can bolster self esteem and group morale. Keep your standards high, but allow as much flexibility as possible in how the work gets done. If you set clear standards, but give employees some freedom in working out ways to meet them, they will probably be able to develop approaches that fit the contingencies of the stress situation. Check on how much flexibility you have with regard to such conditions as work hours, administrative leave, alternate work sites, etc. It's natural to assume that the way we have always done things is the only way, but you and your employees may have options that you haven't considered.

Make it clear that this is a difficult period, and it's OK to share feelings of anxiety, fatigue, or frustration. If you set the example by letting people know you can do a good job even though you are not feeling your best, you can set a positive example. Define the situation in a way that emphasizes the strength of the group while acknowledging the challenges it faces. The tone should not be, "Poor us," but rather, "This is hard, but we're going to hang together and get through it."

Acknowledge the value of professional counseling, and encourage your employees to get whatever help they need. Long term stress can wear down the coping resources of the strongest person, and it makes sense to get extra support in order to preserve mental and physical health. One strategy is to bring in an Employee Assistance Program (EAP) counselor to talk to the group about stress management. Besides learning from the presentation, your employees will develop a personal contact which can make it easier to turn to the EAP if they need it.

Don't underestimate the impact of stress on you as an individual. Attend to your own stress management program, and use your resources for professional consultation and counseling. You will find it easier to take care of your work group if you also take care of yourself.