Billing post-denials
A patient came into the office and gave us Anthem Blue Cross and Blue Shield insurance card, so we billed that insurance. Blue Cross denied stating that the patient wasn’t eligible then we billed the patient. The patient comes back after a year later and says, “Oh, by the way I had Cigna insurance.”
So, we bill Cigna insurance, and we get denials stating that it is past timely filing, which we knew would happen.
My question: Is it legal to bill the patient after receiving these denials from Cigna and make them responsible for paying us services rendered? Or, is there a law that forbids us from doing so?
Danielle Bryant
Medical biller
Newington Internal Medicine Primary Care, LLP
Newington, CT
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mike nelson | Feb 11, 2009 | Reply
In this scenario we would bill the patient. I hope there is not a law. The timely denial was not the fault of the office.
Stephanie Smithson | Feb 18, 2009 | Reply
I think it depends on what you contract is and what your EOB says. Also, you need to have a policy in place to address this. We have the same issue here, so we have put into place a policy that says we will not bill past filing limits, however, we will give the patients an itemized bill if they would like to submit.
Carole Sraver | Feb 23, 2009 | Reply
You need to appeal with CIGNA as your contract will state you cannot bill the patient if you are a participating provider. In the appeal provide documentation and proof, of what the patient presented as well as any notes and attempts to contact once you received the denail from the other carrier. If this is denied provide the same information in appeal to your local insurance commissioners offie, they will help if a payer is not sefl funded. GOOD LUCK!
Richard Johnson | Feb 28, 2009 | Reply
In this case you should appeal the timely billing showing that you’ve billed the insurance that the patient provided initially. In many contracts there is an exception if you can show that the organization didn’t simply wait past deadline to file. As long as you can show this you should be in pretty good shape.
Chris | Mar 6, 2009 | Reply
I have had this happen many times with our State Medicaid plan as well. I contacted them and asked them how we should handle these types of situations where they do not provide the information in the timely manner. They told us that it was appropriate for us to bill the patient, as they are that they MUST present their insurance information at the time of service. If they do not, then we are not responsible for the billing. I’ve talked to a lot of insurance companies as well, who say the same thing. Their subscribers are told that they MUST present their insurance cards at the time of service. What I have done in the past is address a letter to the patient explaining that part of the contract arrangement with the carrier is for them to provide a copy of their insurance card at the time of service, since they did not we would be happy to send a letter of appeal, however if they do not cover it is is their responsbility. I also CC the insurance company on there as well. You are only required to bill if you know they have it…I’ve done this with many major carriers and it has actually worked….However, now we don’t have a problem with this anymore as we will not wait that long before sending a patient to collections. This eliminates having this situation…if the patient hasn’t responded in the 90 days, they are gone! Good luck
Krista | Mar 13, 2009 | Reply
Unfortunately I think this is a common scenario. Our company has addressed this issue in our Admissions agreement which states that we bill all primary and secondary insurance as a curteousy and if the insurance denies for any reason they are responsible to pay the balance.
Greg Stenger | Apr 1, 2009 | Reply
This is all to often a scenario the provider faces. An earlier statement made regarding the subscribers responsibility is correct, the insurer does require the subscriber to present their ID cards at the time of service and the provider usually has a statement that they do bill third-party payors as a courtesy. This is correct for those non-contract payors; however, for contract payors the claims must come from the provider. It is appropriate when the subscriber does not tell the provider of a third party-payor whether the payor is contract or non-contract that any portion of the bill will be self-pay. This issue happens frequently with ED patients, direct patients, some diagnostic patients when the information is not provided by the physician’s office and don’t forget those accounts assigned to a collection agency when a guarantor tries outdated information with them. Therefore, every organization should have a policy addressing acceptance of ID Cards or insurance information. In the content of the policy a statement should be made about the acceptance of contract and non-contract information when the coverage is out-dated (timely) For example, insurance cards are accepted up to XX days following the date of service or up to the point of the payor’s timely filing limits. The subscriber is advised of this when out dated coverage is presented (document throughly). How the timely filing date is defined is in the contract the provider and subscriber has with the payor. To determine what your process will be, review the payor contract and if this situation is not addressed then there is direction of what to do. If not the then the provider has choices. One being not to accept the assignment of insurance since it is worthless and bill the patient. Second to bill the payor and when the claim is denied submit an appeal along with a detailed explanation. However, in the second process an issue takes rise to the point where coverage notification is accepted by the provider who then presents a claim to the payor which is denied because of timely filing, this would be the normal course of any claim. What are the contract provisions for a timely filing denial? Unless this situation is specifically addressed in the contract the amount billed to the payor is a write-off due to the acceptance information, the billing to the payor and timely filing. In this situation it is advised to have the policy reviewed by your attorney and approved by senior managment as state regulations can change from state to state.
Tamara Thivierge Greiner | Apr 3, 2009 | Reply
As a reimbursement supervisor managing over staff who complete insurance claims billing and finanical registration; yes I agree the consumer would be responsible for that bill in which they provided insurance cards a year later. Many times clients/patients believe they have no time limit on filing claims, or they are assuming they can get a reduction if are self pay or they just do not want their medical history data given to the insurance payer. The best situation is the client is honest and provides insurance coverage at the first time registration. There are benefits for the clients/patient to do this; they are saving money cause the patient’s subscriber is usually paying premimums to get medical coverage, also this new medical service will assist in eating down their yearly deductible if it has not been met yet, in addition to helping them when file IRS taxes.
I would charge the client/patient full fee for misleading the registration and billing claims staff. If they owed a copayment according to their policy I would ask for that too or jsut the full fee. Collecting copayments are to be revenue for the office and requested at time of each medical visit. The client/patient fibbed about that information too when he or she denied having medical insurance coverage at first appointment.
Kim M Giraldo | Apr 6, 2009 | Reply
Your timely filing limit “starts” the day you receive the correct insurance information. If you must appeal, then include all documentation of when you submitted the original claim to the incorrect insurance carrier. This information will prove that the claim was submitted timely, even though it was to the wrong insurance. You can only send the claim to the carrier that was provided to you by the patient. These denials are very easy to overturn.
Jason Housenbold | Aug 13, 2009 | Reply
I have a question..
We filed a claim that was denied on the front-end and was never corrected an resubmitted. We have proof that we initially tried to file the claim.
What reasons could we use to appeal such a claim?
Thanks!
Dom Nicastro | Aug 27, 2009 | Reply
Hi Jason:
Would you like me to post this on our weekly e-newsletter?