Insurance Carriers Get Tough With Timely Filing Denials

Most insurance carriers have a rule regarding the filing of insurance claims.  Some such as Medicare allow up to 365 days from the date of service and others only allow 30 days.  Most allow something in between.  Many of our local Blue Cross Blue Shield policies allow 120 days.  In any case, as the biller it is our job to make sure the claims are filed timely.

In a perfect world this would be no concern.  Claims would be filed, in a timely manner and paid on the first submission.  But ahhhh……reality.  We try our best to submit claims timely but sometimes there are things that just prevent us from doing so.  The patient provides us with the wrong insurance information, or their insurance didn’t change but their id number did and they didn’t give you a copy of the new card.  Or maybe they weren’t even aware it had changed!  There are many other reasons that can cause delay in submission.

All of these reasons, valid as they may be, can cause delays in getting the claim submitted to the insurance carrier.  At least they delay the claim in being submitted CORRECTLY.  So often we are faced with denials from the insurance carriers that state that they claim was not filed timely.  In most of the cases the claim was at least attempted to be filed, but either failed at a clearing house level or was denied for invalid information.  It will depend on what the problem is and how the insurance carrier deals with it.

For our local Blue Cross Blue Shield, if you submit a claim with an invalid id number, or an old id number it will deny at the clearinghouse level stating “subscriber not found”.  In this case there is actually no claim ever on file with Excellus since they rejected the electronic submission.  So if you were to call they would not even know a claim had been submitted.

So how do you deal with these timely filing denials?  Up until recently they were not that difficult to appeal.  We would simply print out a patient ledger from our practice management system, attach it to the claim with a generic letter we stapled to the front explaining that we were appealing the timely filing denial.  The patient ledger showed the first date submitted, the last date submitted and the number of times the claim was submitted.  With that simple system 99.9% of our appeals were reprocessed for payment.

In recent months insurance carriers have been cracking down on timely filing denials and requiring more proof.  No longer do they accept the patient ledger as proof of the original submissions.  Now they are requiring that you not just show the original submission but that you show what was done in between.

For example, if we submitted a Blue Cross Blue Shield claim with an invalid ID number and then by the time we corrected the id number the claim was past the filing limit.  The correct version of the claim is now denied for timely filing.  In addition to the patient ledger we also have to submit an insurance aging report that shows not only the first and last submission but actually shows each and every date the claim was submitted.  In addition to that, we have to state if the claim was submitted  electronically or on paper.  If electronically, then we have to include clearinghouse submission reports showing what happened to each claim that was submitted.  Was the claim rejected?  Did we have ample time to correct the mistake?

Most insurance carriers not only have rules about the time frame a claim must be submitted but also how much time you have to act if a claim is rejected.  For example, if you receive an electronic rejection stating subscriber ID invalid, you may only have 120 days from the date of that rejection to take action.  So if you get a rejection and then you contact the patient for the correct information, if they do not get back to you quickly you may not be able to appeal the denial.

If the claim was submitted on paper you may have to include a written explanation of all steps that took place involving the claim.  For example, you might indicate that the claim was submitted on January 5th  on paper and you received a denial on February 8th stating “patient not covered under policy”.  So you send the patient a bill asking them for the correct insurance information.  Maybe the patient is in Florida for the winter and they don’t respond to you until April.  You would need to write up an explanation to submit with your proof of the original submission.  You would also want to include a copy of the original denial.

The point is that insurance carriers are getting tougher with their timely filing guidelines.  The best option is to get all claims in timely.  But for those few that you just can’t seem to avoid, make sure you clearly show your proof with all evidence that you have available.  Otherwise most likely they will uphold the denial of timely filing.

More Marketing Campaign Results

May 20, 2013


Made 3 calls to phone appointments – 1 appointment is supposed to be tomorrow but we will be in court all day and unable to call at the scheduled time.  We should have blocked out that day on the scheduling calendar but didn’t think of it.

1st call – They are fine and don’t need anything fixed.

2nd call –  In a meeting – call back later

3rd call – This call was quite interesting.  They were not interested in the free analysis but they were opening a second vision office and were currently billing in-house.  They realized that once they start getting busy in the second office they would not be able to handle the billing for two offices and were interested in talking to us.  She asked if she could keep our number and give us a call as soon as they got the office established.

This made us question our offer.

May 28, 2013 – 4 more leads generated with one phone appointment.

1st lead

We sent the info to the office manager who had indicated on the call that they have 3 different offices and were very interested in receiving information.  She agreed to a phone appointment for the following Monday but didn’t know which office she would be at but if we called they could locate her.

We sent the information and received the following email from her the day prior to the phone appointment.

I did receive your email.  We do our billing in house through Medent’s integrated PM and EMR system. We bill electronically, have two seasoned and skilled billing people and our A/R is excellent.  You are offering a great service, but it is not one that we need at this time.

Thanks so much,


Makes you wonder why she agreed to the phone appointment in the first place.

We decided to ask our contact at the marketing company about this and he suggested we talk to one of the marketing gurus at the company.  We were contacted by Kelly who spent an hour with us going over everything.  He looked into the scripts and offers of other medical billing companies to compare both the numbers and the results.  We decided to try a different offer that has been effective for some other billing services.  Kelly also asked us what who makes our telephone appointment calls and what happens when we make them.  He made some good suggestions about our handling of these calls and explained exactly how the calls are set up.  Kelly also explained how the follow up emails work.

We have decided to use an offer that is working well for another billing service which is that we offer a free first month’s service up to $1000.00 if they sign a one year contract.  We are concentrating on 3 specialties and using this in our phone script.

We also heard from another billing service using the program that did set up a face to face appointment with a lead for next week so we wish the best for them.   We have calls being generated this week again with our new offer so let’s see what happens with this.

One of the things that we realized after talking to Kelly was that we didn’t fully understand their system and we were trying to implement our own system as soon as they got the lead.  We were actually working against each other.  At first we thought that our system might be better since we know the industry but after talking to Kelly we agreed that their targeted email system is better and we are just confusing things by sending ours.  Also, this is a numbers game – we knew that.  But we were contacting anyone that agreed to receive our info and that was also a mistake.  The only leads we should have been contacting by phone were the ones who had set up phone appointments.  All of the others were being sent a very targeted string of emails still trying to interest them.  So by calling them we were interfering with the marketing company’s system.

So even though we still have not signed a client we are very excited about moving forward.  Now that we have tweaked our offer and understand the entire system we are confident that we are moving the right direction.  We are very impressed with the company overall.  When they realized we were not happy with our results they were quick to get in touch with us so that we could work on what was happening and make improvements.