Timely Claim Filing vs Coordination of Benefits

[MedicalBiller]

What is the name of your state? Utah

To set the stage for my question I need to explain two aspects to my issue. First, medical insurance companies include in their policies time limits for filing claims which is typically about a year to a year and a half from the date of service. Second, many people have two insurance policies, usually one through their own employer and another through their spouses employer but there are many other scenerios for a person having two insurances. Patients often do not understand how it is determined which of their two policies is billed and pays first and which pays second. If patients are unclear on this and they do not provide each insurance with accurate information on their other insurance the coordination of the two policies can be quite a mess for providers trying to be reimbursed for their services.

My question has to do with where these two issues collide. Often, after an insurance has paid a claim as though they were the primary insurance for a patient it will later discover it was not the primary insurance. Now because of electronic funds transfers they merely take there money back. Apparently there is no time limit on how long after the initial payment these monies can be retracted. Often they will take money back years later. This is of course a problem for providers. Claims submitted late now to another insurance which is now considered the primary insurance are denied for being filied beyond the timely filing limit. Providers then have to appeal the denial explaning the coordination of benefit problem. Appealing these denials does work in many cases but not always. Most recently the problems I have had on this have been with Medicare. They may consider payment if the provider had submitted a timely claim for secondary benefits but if no claim had been submitted at all they deny the claim. This can happen when the provider had not been made aware the patient had Medicare and had no reason to consider it because another insurance had paid the claim.

I do not believe there are policies regarding this type of issue in insurance/provider contracts. Are there laws for this type of issue? If ultimately payment is denied by the insurance who is liable the provider or patient? When dealing with Medicare who would be liable?

One example I can give of many would be if a patient comes in with a Medicaid card which the provider bills and Medicaid pays in full. 2 years later Medicaid requires their money back because they say the patient had Medicare. Medicare denies for timely filing with no appeal rights. Is Medicare, Medicaid, the provider or the patient liable?

This issue is not always with Medicare and Medicaid. It occurs with regular companies as well in a variety of scenerios. I work as a billing supervisor so I'm on the provider side of the issue and seek clarification of provider rights when this occurs.

Any guidance would be greatly appreciated. Thanks!

[moburkes]

The patient is ultimately responsible.

[ecmst12]

If a patient has medicare AND medicaid, billing the patient is going to be pretty pointless. Besides, timely filing denials are typically NOT billable to the patient if the provider has a contract with the insurance company.

If the provider can show that they did submit to the incorrect insurance company within the filing limit, and did not find out until much later that it is incorrect, then the correct insurance company SHOULD consider the claim without regards to timeliness. But policies vary from company to company and Medicare is a special case. I don't believe that a doctor that participates with Medicare could bill the patient for this type of denial.