Magazine article Medical Economics

Practice Management Q&A

Magazine article Medical Economics

Practice Management Q&A

Article excerpt

Filing untimely claims

Q: If a patient who is covered by a managed care plan, Medicare, or Medicaid fails to notify our practice that he or she has coverage until after the timely filing limit, should we still file a claim?

A: Many managed care plans indicate in their contracts the time frame for timely filing. You still may file a claim after that date, explaining that the patient has just informed you that he or she has this insurance. If the plan denies the claim, then the patient would be responsible for payment. If he or she doesn't pay, then you could choose, eventually, to send the account to collection.

For Medicare, the limit for timely filing generally is December 31 of the calendar year after the year in which services are furnished. For services provided in the last quarter of a year, claims may be filed timely through December 31 of the second year after the year in which such services were furnished. Thus, services that were provided in November 2009 may be filed in a manner considered timely through December 31, 2011.

Medicare claims may be filed past those time limits, although a percentage reduction in payment will occur. When filing the late claim, it is important to provide a detailed explanation for the delay. If a carrier does not find good cause for the delay, then it'll send a reduced reimbursement amount and indicate that the patient cannot be charged for the reduction. If you don't receive this notice, then the carrier should pay the full amount.

Generally speaking, if you have a good cause for the delay, then submit the claim with a detailed explanation. Much of your success in getting paid will depend on how much time the patient has taken to inform you of his or her coverage and the reason for the delay.


Q: I understand that the Centers for Medicare and Medicaid Services (CMS) is changing its audit criteria and the way it calculates what it deems to be improper payments. …

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