What Medical Practices Need to Know about Timely Filing

Many factors, from multiple coding systems to billing and documentation requirements and insurance policies and guidelines, make medical billing a complex process. Timely filing of claims is a crucial part of medical billing services and can greatly impact a healthcare provider’s revenue. Timely filing also plays a role in minimizing billing confusion for patients and fosters transparent communication with them.

Insurance payers impose strict deadlines for claim submissions, and mastering timely filing is essential to adhere to those limits. Submitting claims promptly enables healthcare providers to optimize their cash flow. Timely reimbursement is essential for maintaining a steady revenue stream and meeting operational expenses. Delays in claim submission can lead to prolonged payment cycles, causing financial strain for providers. Non-compliance can result in penalties, loss of reimbursement, and damaged relationships with payers.

Let’s dive into what medical practices need to know about timely claim submission.

What is Timely Filing and Why is it Important?

Timely filing refers to the specific timeframe within which healthcare providers or medical billing companies should submit claims to insurance companies for reimbursement. Each insurance company has its own timely filing deadline, which is typically outlined in the provider’s contract with the insurer or in policy documents. Meeting timely filing deadlines isn’t just about financial stability; it’s a fundamental aspect of ensuring patient satisfaction and smooth medical practice operations.

Providers’ manuals are released online and contain comprehensive information about the insurer’s procedures for submitting claims and reimbursing healthcare services. If a specific insurance company has established a deadline for timely filing, you can locate this information within their provider manual, typically in the section related to claims.

The timely filing limit typically ranges from 90 to 180 days from the date of service. Medicare’s timely filing limit is 365 days. Here are the timely filing limits of a few leading insurance companies for 2023:

• Aetna120 days from date of service
• Blue Shield1 year from date of service
• Cigna for Participating Providers90 days from the date of service
• EmblemHealth for Participating Providers within 120 days post-date-of-service
• Unitedhealthcare Participating Providers90 days from the date of service

For example, suppose a patient undergoes a medical procedure on January 15th. The insurance company they are covered by has a timely filing limit of 90 days from the date of service. To ensure timely claim filing, the healthcare provider has to submit the claim to the insurance within the 90-day window. So, if the provider files the claim to the company on March 15th, the insurance company will review the claim and process it for reimbursement according to their policies.

Now suppose the claim was not submitted to the insurance company until July 1st (more than 90 days after the date of service). This would be considered untimely claim filing. The insurance company may automatically deny the claim due to late filing with denial code CO 29, and the healthcare provider might need to absorb the cost of the services provided or seek alternative means of reimbursement.

What is a Timely Filing Write-off?

While the insurance company might deny the claim due to late filing, the patient is typically still responsible for the cost of the services they received. In other words, if a patient receives medical services and the insurance claim is not filed within the required timeframe or is denied for any reason, the patient will need to pay for the services out of their own pocket, since the insurance company is not covering the expenses.

The purpose of health insurance is to help individuals manage the financial burden of medical expenses. When a claim is approved, the insurance company typically covers a portion of the costs as outlined in the policy, while the patient is responsible for paying the remaining portion, such as deductibles, copayments, or coinsurance. The denial of the insurance claim due to late filing does not absolve the patient from the financial obligation to pay for the services received.

It’s essential for patients to be aware of their insurance policy’s terms and conditions, including the deadlines for filing claims. By understanding these requirements and meeting them promptly, patients can increase the likelihood of their claims being approved and minimize the potential financial burden of medical services.

A timely filing write-off occurs when a healthcare provider or medical billing entity decides to write off a patient’s outstanding balance instead of pursuing payment from the patient. Timely filing write-offs have a financial impact on the healthcare providers as they essentially absorb the cost of the services that were not properly submitted to insurance. So it is important to be aware of the deadline and submit the claim promptly.

What are the Challenges in Meeting Timely Filing Requirements?

Meeting timely filing requirements in medical billing can be challenging due to various reasons. Some common challenges include:

• Complexity of documentation: Preparing accurate and complete documentation for claim submission requires careful attention to detail. Gathering all the necessary information, including codes, descriptions, patient details, and supporting documentation, can be time-consuming.

• Payer changes and updates: Insurance companies can change their claim submission requirements, timely filing limits, or policies. Staying updated on these changes and adapting processes accordingly can be challenging.

• Coding errors: Accurate medical coding is essential for proper claim submission. Mistakes in coding, such as using incorrect codes or failing to provide sufficient details, can lead to claim rejections or denials. When claims are denied, the appeal or resubmission process can be time-consuming, affecting the overall reimbursement timeline.

• Delays in data entry: When dealing with a high volume of claims, entering data into billing systems accurately and promptly can be challenging. Data entry errors can lead to delayed claim submissions.

• Incomplete information: Gathering complete and accurate information from patients and healthcare providers can be challenging. Incomplete patient information or missing documentation can lead to delays in claim submission.

• Hitches in provider-payer communication: If communication between healthcare providers and insurance companies is slow or unclear, it can lead to delays in obtaining necessary information for claim submission.

• Delays in insurance verification: If there are delays in patient insurance eligibility verification, it can impact the timely submission of claims.

• Provider workflow problems: Bottlenecks or in efficiencies in a practice’s internal processes, including technology issues, can lead to delayed claim submission.

Adequate staffing and ongoing training are crucial to ensure that billing personnel are well-equipped to handle claim submissions promptly and accurately.

Strategies to Reduce Timely Filing Denials

They should implement efficient billing workflows, ensure accurate documentation and coding, maintain up-to-date software systems, offer staff training, and maintain effective communication with payers. Strategies to ensure timely claim submission include:

Ensure complete and accurate documentation: Progress notes serve as the foundation for accurate claim submission in medical billing. The link between progress notes and claim submission is a crucial aspect of medical billing and reimbursement. Progress notes are an integral part of a patient’s medical record and provide detailed documentation of the services provided during a medical visit. They ensure that the services provided are properly documented, coded, and substantiated, leading to successful reimbursement from insurance companies. Ensuring clear, comprehensive, and accurate progress notes is crucial to support effective patient care and for smooth and efficient billing processes.

Perform insurance eligibility verification: Insurance eligibility verification is closely tied to timely claim submission in medical billing. It ensures accurate claim submission, reduces denials, and enhances overall efficiency in the billing process. Patient coverage and eligibility can change. Verifying insurance eligibility ensures that the patient’s insurance coverage is active and valid on the date of service. Leveraging insurance verification and authorization services can prevent the submission of claims for services that won’t be covered due to lapsed or incorrect insurance information. By confirming coverage and benefits before services are rendered, healthcare providers can proactively address potential issues and provide better financial clarity to patients.

Know payer-specific claim submission deadlines: Make sure you know the timely filing limits of the different healthcare insurances your patients use. Go to the PROVIDER section of a payer’s website to find their timely filing deadline. Having this information handy is especially valuable for large organizations that bill out on a monthly basis.

Look out for missing claims: With all the challenges involved in submitting claims on time, medical practices need to have an efficient system in place to make sure that all of their claims are actually being billed. Frequently, healthcare providers may overlook visits that haven’t been assigned codes and billed Missing claims refer to healthcare services that have been provided to patients but have not been properly documented, coded, and submitted as claims for reimbursement to insurance companies or payers. These claims are essentially omitted from the billing process, leading to potential financial losses for medical practices. A Medical Economics article notes that generating the “appointments lacking associated charges” report from the Electronic Health Record (EHR) system can facilitate streamlined follow-up on any outstanding claims that might have been missed.

Appeal denials: Most medical billing companies use a clearinghouse to consolidate claims into a single comprehensive file, which is then sent to insurance companies. These claims are subsequently reviewed by the insurance companies for reimbursement. If you find that your claims are being denied due to untimely filing, search the clearinghouse’s website for evidence that the claim was received and accepted by the payer. Once you establish this acceptance, you can appeal the denial. Sending a concise letter with essential patient details such as name, date of birth, and policy number, accompanied by proof of the payer’s acceptance and unwarranted denial, can result in the successful payment of the claim. Although most payers stipulate a review period of 30 to 90 days for appeals, presenting such substantiated proof should lead to a favorable resolution and eventual payment (www.physicianspractice.com).

Different insurance companies have their own policies, guidelines, and reimbursement structures. In the intricate landscape of medical billing, mastering timely filing emerges as a fundamental skill. By understanding its nuances, challenges, and potential strategies, medical practices can optimize their billing processes, secure proper reimbursements, and maintain a healthy financial stance. Healthcare providers can rely on trained specialists in medical billing outsourcing companies to handle their billing processes effectively, submit timely claims, and maximize reimbursement while maintaining compliance with regulations and payer guidelines.