Deductible - Heal Your Practice

Now that the holidays are behind us, it's time to get back to work.  January is when commercial insurance companies and Medicare takes your claim payment and applies it to the patient's deductible. The deductible, an out of pocket expense, can be hundreds of dollars.  One question I am asked is, "Can I delay sending my claims to the insurance company or Medicare?  Some providers believe that by delaying the submission of the claim, the claim payment won't be applied to the deductible and the provider receives checks. The provider is hoping other claims are applied to the deductible first.  If the payment is applied to the deductible, the provider has to spend additional money by billing the patient. Some patients refuse to pay their deductible. The answer to the question can be found with claim submission timeframes in State Insurance Laws, Medicare, and physician insurance contracts.  All of these inform you of how long you have to submit the claim. 

State Insurance Laws

Here in Florida, if you look at Florida Statutes 627.6131 (Commercial) and 641.3155 (HMO) you see that both state the following:   All claims for payment or overpayment, whether electronic or nonelectronic: Must be mailed or electronically transferred to the primary insurer within 6 months after the following have occurred: 1.  Discharge for inpatient services or the date of service for outpatient services; and 2.  The provider has been furnished with the correct name and address of the patient's health insurer.


Claims must be submitted by the end of the calendar year following the year in which the services were rendered. 
If the patient was seen between:  October 1, 2008 and September 30, 2009, the claim must be filed by: December 31, 2010.  If the patient was seen between October 1, 2009 and September 30, 2010, the claim must be filed by: December 31, 2011
Provider Insurance Contracts
Check the provider's contract with the commercial insurance company.  The contract will inform you of the agreed upon claim submission timeframe.  Some contracts may require the provider to submit the claim within a 90 day time limit.
Even though you may have time to submit the claim long after the patient was seen, there is no guarantee the deductible has been met and you might forget about sending the claims.  By the time you catch the mistake, the time limits have passed resulting in the claim being denied for timely filing.  
Finding Revenue for Your Practice
January through March can be financially lean months for medical practices.  You have claims submitted in November or December that can take 60-90 days to be paid, but you do have unclaimed money available to you. Some of this money may be lost if you wait too long to do anything.  You may have claims that remain unpaid with contracted insurance companies, Medicare, Medicaid, auto accident, workers compensation and non-contracted insurance companies.  I recommend looking at your billing software's insurance aging report.  Find claims that are older than 60 days from the date of service.  This is where your money sits waiting to be paid. If you don't do anything, this money may be lost forever. You want to show due diligence with following through with the claims payment process.  I suggest reprinting each claim for every insurance company that is contracted with the provider.  Once they are printed, resubmit the claim to the insurance company provider representative (rep) or CEO.  If you send the claims to the CEO, send them by Certified Mail/Return Receipt Requested.  This is to ensure that the claims do not become lost or not on file.  I also suggest that you require the insurance company enforce the payment terms of the contract. With the remainder of the old, unpaid claims, I suggest reprinting them and resubmit them, also to the CEO, making sure that there are NO errors.  Medicare and Medicaid claims can be resubmitted electronically.  With the remaining unpaid and non-denied claims, I suggest resubmitting them, by Certified Mail/Return Receipt to the CEO of the insurance company.  If you have unpaid claims that are older than 90 days old, you ave a problem that needs to be identified and corrected.  Heal Your Practice has experts in AR Recovery, appeals, and insurance contract review that can help you strengthen your weak areas and with your revenue issues. 

By Steve Verno
TransformU and Heal Your Practice