Let’s say that you went through the entire process of submitting a claim, ensured its accuracy, scrubbed it with the help from your clearinghouse and sent it before the insurance organization’s deadline.Īfter all of that, though, a few days go by and you still receive a timely filing denial for that claim. If you don’t submit a claim within the deadline provided by an insurance organization, it’s going to get denied and you’re going to have to write an appeal letter. That’s how timely filing denials happen in a nutshell. Of course, in this example the 180 limit passes by faster than you anticipated, you submit the claim and receive a denial. You can see how things can get out of hand. Those patients likely all have different insurance providers…not just Vermont Medicaid. While all of those processes happen, your organization needs to continue to see more patients. There are a lot of checks and balances both within your organization and with your clearinghouse to ensure accuracy. Well, as you likely know, submitting a claim to a payer isn’t as easy as it sounds. So, if a patient had an appointment at your facility and they used Vermont Medicaid as their insurance, you would have half of a year to submit that claim to Vermont Medicaid. It goes on to detail some minutiae scenarios that includes paper claims and inpatient claims but the deadline doesn’t change. In this example, the timely filing limit for primary, maternity and orthodontia claims is 180 from the begin date of service. The image above comes from Vermont Medicaid’s provider manual. It’s usually detailed within an insurance organization’s provider manual. This requirement is nothing more than a deadline to submit. You see, this type of denial is nothing more than an indication that you failed to meet a particular requirement placed on the payer.Īlmost every insurance organization places a timely filing limit on submitted claims. If insurance payers didn’t place requirements on the claims they recieve, the reimbursement process would take even longer than it already does.Īll of this brings me to timely filing denials. They deal with thousands if not millions of submissions from providers all across the country on a daily basis, so they have no choice but to put up guardrails. Although it might sometimes feel like insurance organizations just don’t like claims that come from your organization, that’s not the case. I want to preface this by saying you shouldn’t take denials seriously. In order to have any success appealing your timely filing denials, you need to understand what happened to your claim. That’s exactly why I’m writing this blog post, here are 3 effective appeal letter for timely filing samples. If you have a pile of timely filing denials, there’s still hope to receive payment for them…it’s just a matter of knowing what to do and how to execute the steps properly. Out of all of them, though, there’s one in particular that stands out from the crowd more than the others because it happens a lot and it’s super easy to avoid…timely filing. Taking a look at the reason codes you receive for your denials will give you a better idea as to what processes you need to change in the name of boosting your revenue.Īfter being a clearinghouse provider for over 20 years, though, we’ve started to notice some trends regarding the most common types of denials. It’s a good thing insurance providers include a reason code in the electronic remittance advice that they send back to your clearinghouse provider. Of course, the next piece of that puzzle is determining the most common types of denials your organization sees the most. Those two data points are the reason why I made the frank remark that it doesn’t really matter how well or poorly your organization handles claims that come back from insurance providers with a denied status, there’s always room for improvement. More than 85% of denials are potentially avoidable and one-third of them are absolutely avoidable. Regardless as to how well or grim the denial landscape at your organization looks, though, I have a more helpful statistic for you to know. In other words, your organization’s average denial rate is going to be different from the mental health facility up the street. Although it sounds scary, taking the total yearly cost of denials and dispersing it across the entire industry isn’t accurate. The reality is that the denial landscape is different for every healthcare organization. If the average dollar amount of denials costs providers that much, regardless of the size of their practice, how are they supposed to keep their doors open? If you ran the math and divided that number by the total number of healthcare providers in the U.S., it would amount to around $5 million worth of denials per. $262 billion worth of claims get denied on an annual basis according to HFMA.
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