Question regarding time limits for claims

[rdemo]

What is the name of your state (only U.S. law)? NY

I have a question regarding expiration for filing claims and obtaining payment for services.

My wife had a follow up imaging exam done last September. This was a follow up test to a routine yearly breast exam. The follow up was needed because there was an abnormality that turned up in the routine exam a few months earlier.

The lab performed the test and filed a claim with my insurance, Blue cross/Blue shield. The insurance company rejected the claim on the same day that the claim was filed (in September) because my wife is only alloted one routine procedure a year. Follow up imaging exams required a diagnoses code to be attached to the claim. The medical provider filed the claim incorrectly.

I did not know this happened. I recived a bill, for the first time, from my medical provider two days ago, 10 months after the service was performed, asking for payment because my insurance denied coverage ten months ago. My provider basically did not do anything to seek payment from anyone for 10 months.

After promptly talking to my insurance, I realized the problem. However because Blue Cross has a 6 month time limit to challenge claims, My provider can not refile the claim under the proper service code. The provider has said that under NYS law they are allowed to bill for services up to 7 years from the date when it was provided. My insurance has a time limit of 3 months and for six months to challenge a claim.

Am I responsible for this bill given the providers negligence in not promptly dealing with the matter? If so, what was I supposed to do? Couldn't all providers simply wait 6 months and then bill the patient directly and then never have to deal with the insurance companies? Doesn't the service provider enter into an agreement with the insurance provider when they accept the insurance that would indemnfy me from this bill?

Any insight regarding NY sate law would be helpful?What is the name of your state (only U.S. law)?

[ecmst12]

Since the doctor submitted the ORIGINAL claim within the timely filing limit, they have met that requirement and should be able to resubmit the corrected claim and receive payment.

IF for some reason your plan doesn't work that way and the corrected claim is still denied for timely filing, then as long as that doctor is contracted with your insurance, you CAN NOT be billed for this denial. But more likely, the claim will be paid.

[rdemo]

thanks ecmst12:

IF for some reason your plan doesn't work that way and the corrected claim is still denied for timely filing, --

the claim was denied because the provider sat on it after it was originally rejected. The insurance company has a time limit for challenging a rejection.

then as long as that doctor is contracted with your insurance, you CAN NOT be billed for this denial.

Why can I not be billed? Does the provider enter into a contract with an insurance provider that prevents them from coming to the patient?

But more likely, the claim will be paid.

Why would the insurance company offer to pay it if the provider just sat on a bill for 10 months? The insurance company has a stated time limit. Are the time limits legal?

[ecmst12]

The time limits are legal and written into the contract between your doctor and your insurance company. And since your doctor signed the contract and agreed to the time limits, he can't bill you for his failure to file timely. He has to write it off.

If he's NOT contracted, he can do whatever he wants and you are responsible. The contract is the only thing that protects you.

Most likely, you are being billed because the denial was marked as "over plan limit for routine services", not "outside timely filing". If you call and remind the billing department of their error and that they are contractually banned from billing you for their failure to submit the corrected bill within the time limit, the bills will stop. If they don't, you can complain to your insurance company.

[lkc15507]

[quote=rdemo;2296463]What is the name of your state (only U.S. law)? NY


I hate the answer I am ultimately going to give. First, I applaude your knowledge/research regarding this isssue. Unfortunately, the one thing that is missing is the fact that the insured is ALWAYS, but ALWAYS responsible for proper payment of claims.

I'm going on a soapbox here in that I agree that if a contracted provider receives payment on an incorrectly adjudicated claim, even (especally) if their fault for improper coding, the provider should have a contractual obligation to appeal and rectify the claim on the behalf of the insured. Sadly, that is not (ever as far as I know, but possible) the case. You stated your unawareness of the situation. However, the Explanation of Benefits by your payer at the time of the original submission was your notification of the problem. Laws with regard to the timely filing of claims vs. how long the provider has to bill are two completely different animals.

It is a simple fact that health care facilities routinely audit their books. Unfortunately, their audits usually exceed the timely filiing of virtually any health plan. If the audit returns an unpaid balance, the provider may legally bill you for the balance up to several years. In your state specific case, 7. So, my advice to you is 1) appeal the claim to the insurer according to the procedures in your plan document. Don't play victim or stupid, challenge the timely filing based upon ecmst's advice, the original claim was filed timely. (Since it was not properly coded etc., the insurer can claim they had no obligation to pay. You will challenge, in that they received a claim and had an obligation to request correction, more info, clarification, whatever) 2) Now you have a problem with the appeal being filed timely. That appeal timeframe is based on when the insurer issued the original denial EOB, they would have sent you a copy, thus making it your problem. This is the hardest to overcome. But, it can be defeated. I'm just not sure how. ;-) Okay, this will get a little complicated, but what you need to do is reset the clock. Go back to #1. IF the claim was timely filed ( you need proof from the provider), the appeal clock sets when the insurer responded to the first communication from either you or the provider. (ie, insurer states they did not receive timely, ie, how can you respond timely?) Clear as mud I'm sure. This is winnable on appeal. But, please, please, please, please do NOT try the "I didn't know, I'm a victim" card. Sure loser if you do. Smart appeals, read the plan doc, proactive, attack with the plan doc's own words.