Ophthalmology and Optometry Coding Alert

Hint: Track all claims to stay on track.

Although most practices have become accustomed to filing claims within Medicare’s 12-month timely filing window, some are finding it difficult to stay within that timeline. Several practices have written to Ophthalmology and Optometry Coding Alert expressing frustration over losing out on reimbursement due to late filings.

To stay on track with your claims, check out the following three tips.

1. Keep a Chart and Stick to It

Timely filing means that your practice submits a Medicare fee-for-service (FFS) claim within 12 months. Ever since the Affordable Care Act went into effect, claims must be filed within one calendar year after the date of service. Medicare will deny your claim if it arrives after the deadline date, so your practice has to stay on top of claims.

Not all insurers follow the 12-month limit. Some private insurers will allow you to report your claim for just 60 days after the date of service, while others give you more than a year to submit your claim.

Therefore, you should get to know the filing deadlines of each insurer you bill. Perhaps the easiest way to keep track of multiple payer timely filing rules is to make a chart (such as a spreadsheet) that lists each insurance company’s timely filing limit. If you do have a backlog of claims in your office, separate them out by insurance company so you can use your chart to quickly identify the payer with the shortest limit and work on those claims first.

2. Make Sure You Keep Proof On Hand

One good rule of thumb is to always keep proof of the electronic filing in your files.

Option 1:  You can use a claims clearinghouse that stores your confirmation of receipt by your payers so that you can access them on demand when you need to appeal timely filing denials. If your clearinghouse does not provide this service, consider changing to one that does.

Option 2: If your practice does not want to or cannot change its process, the alternative is to print these confirmations on paper. You might also save them as PDF files when you receive them from your clearinghouse and store them locally on your computer so that you can use them to prove timely filing.

Keep in mind: Timely filing denials from payers are not always correct. Pull your electronic confirmation reports and see if you have proof that the claim was in fact submitted on time. This will give you ammunition to appeal the denial.

3. You Have Options if the Patient Held Up the Claim

If your practice had the claim ready to send, but the patient did not provide his insurance information in time, you may have a few options. You can

1. Appeal
2. Write off the claim
3. Follow-up with the patient for the money.

The only time you can submit a bill to the patient after the timely filing deadline and successfully seek payment is if the patient did not provide you with the proper information before the filing deadline. The payment then becomes the patient’s responsibility, and you should bill the patient rather than write off the claim amount.

Here’s how: To appeal when the patient delays insurance information, send a letter to your payer and include a printout from your system that shows the insurance information and when the patient gave it to your office. In the letter, ask the payer to rescind its denial based on timely filing and instead deny the claim as the patient’s responsibility because the patient failed to provide insurance information.

If you use an electronic system, you can easily keep track of when patients call in and make changes to their insurance as well as when you get copies of new insurance cards. This documentation will help you prove when the patient gave you their insurance information.

Good news: Some billers say that they’ve successfully appealed timely filing denials when the patient did not provide the information until after the filing limit. You can try appealing the denial, explaining that if the patient had provided you with the correct insurance information, you would have filed the claim within the proper amount of time. You may want to include documentation showing when you first billed the patient and a history of all other statements you sent to the patient.

Exceptional circumstances: There may be times when your practice experiences exceptional circumstances, such as a hurricane or flood. If a disaster, whether manmade (such as computer crashes) or nature-created (such as tornadoes, etc.), you can contact the payer to assist you and extend the timely filing deadline. Often times the practice will receive one-time extensions due to these extenuating conditions.