Timely Filing and Patient Debt Obligations
If a claim is rejected due to "timely filing" by the insurer, is the patient still financially responsible to the provider?
Submitted by: Ken Fagerman, Outpatient Pharmacist Supervisor, St. Joseph’s VNA Homecare
Response Summary
There were 4 Listserv responses to Ken’s question.
Linda Breakie, Rn, CRNI, Managing Member, Complete Infusion Services, LLC stated: “I would say that the patient is not responsible if the timely filing issue was as a result of your staff. However, I would want to be sure that there's not some evidence in your office that the claim actually was worked and the insurance company is wrong.”
Mike Semon, RPh, President, Caring Solutions, Inc. stated: “We have had this issue several times and depending on your contract relationship with the insurer is foremost whether it is spelled out, secondly we have placed in our provider packet a financial responsibility form where irregardless, the pt is ultimately responsible since we view the billing process as a "courtesy". I have battled this in my mind and look to see how other health care providers have handled this ie. hospitals, Dr.s etc and they are more agressive in patient responsibility ie. no billing to secondaries, one time only billing as a courtesy etc. Still wonder how we in the infusion industry have created this "we are banks" sitting on dollars for the patients we continue to serve and the countless hours we spend on trying to collect those dollars.”
David Franklin, M.S.A., President of Advanced Care Consulting Service & VP Operations, Advanced Care Provider Network stated: “It depends upon how the contract with your payer is worded. When you review the actual terms of the contract I bet that you will find two elements: 1) A timely filing requirement; and 2) a hold harmless clause that prohibits you from billing the patient for anything other than co-payments, deductibles, or non-covered services. If you signed a contract that included those terms, you agreed to them. I could be wrong - not every contract in the world includes those clauses – but I'll betcha...”
Steve Magliacane, Lead Infusion Biller, Community Surgical Infusion stated: “I agree with you Linda. It is not the patient’s fault that someone did not do their job correctly. Untimely filing happens but is avoidable. It is not a "patient billable" denial.”
Rock-Pond Analysis
Understanding Timely filing limits for claims submission are an essential and critical part of operating a successful Home Infusion business. Most commercial and managed care contracts have timely filing limits on average of around 90 days from the date of service. We believe that all contracts (or 99.9% of them) address timely filing limits and hold harmless clauses. Medicare and most Medicaid programs have timely filing limits of 1 year from the date of service.
If you are unsure whether your current software system can track and identify unbilled claims related to timely filing dates, then Rock Pond Solutions can help you establish the process to alleviate this situation. Give us a call at 501-460-6446.