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We thank you for being loyal readers of our weekly Alerts. Our goal is to provide articles focusing on the latest hot topics of interest to the healthcare industry. Our alert is in its 7th year of distribution.

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October 2, 2019

Time marches on.  The clock is ticking and the days are flying.  Though we would sometimes like nothing more than to slow things down and take things easy, the passage of time propels us forward and compels us to take action.  Who among us has not experienced the smoldering stress of having to meet toxic timetables and looming deadlines?  It’s just part of our daily reality.  In 1895, H. G. Wells published a short novel about an inventor who built a machine to master time; but, by the end of the story, time had got the better of him.  Despite attempts to tame it and control it, time tends to have the last word.

Yes, there is little doubt that the underlying pressures that many Americans feel in this fast-paced society are due, in large measure, to the reality and inevitability of the fourth dimension—time.  In recent days, one health insurance company has added one more time pressure to our increasingly hectic schedules.

Running Short on Time

Anthem Blue Cross Blue Shield Healthcare Solutions (Anthem) has instituted a change in its timely filing deadline.  What was once a 180-day allowance for in-network claims and 365 days for non-participating claims has now been considerably shortened.  Notifications have been issued by most of Anthem’s state subsidiaries to the effect that these previous filing deadlines have been changed to 90 days for all professional claims.

States that have issued advisories of this change include California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, New Hampshire, Nevada, New York, Ohio and Wisconsin.  This notification was noticeably absent from Anthem’s Virgina website at the time of this writing.  Howerer, this may have been an oversight, as one Anthem representative has informed us that the new 90-day deadline is applicable to all Anthem states.

Some state notifications specified the change was only applicable to Medicare Advantage plans, such as New Hampshire and New York.  In California, only Anthem Blue Cross plans are at issue, as Blue Shield operates independently.  By and large, the typical notification found on many of Anthem’s subsidiary sites contains the following or similar language:

Effective for all claims received by Anthem on or after October 1, 2019, all impacted contracts will require the submission of all professional claims within ninety (90) days of the date of service.  This means claims submitted on or after October 1, 2019 will be subject to a ninety (90) day timely filing requirement, and Anthem will refuse payment if submitted more than ninety (90) days after the date of service.

These Anthem notifications typically include the additional instruction that if the Anthem plan acts as the secondary payer, the 90-day period will not begin until the provider receives notification of the primary payer’s responsibility.

Time is of the Essence

The upshot of all this is that we now have far less time to process these claims.  In fact, that time has been cut by half for in-network services, and we now have nine fewer months to submit out-of-network claims.  What this effectively means is that more claims will likely be denied—unless certain measures are taken by providers and their billing staff.  To lessen the likelihood of denials due to timely filing errors, we at MiraMed recommend the following strategies:

1. Ensure Expeditious Delivery of Your Records.  It goes without saying that providers will need to tighten up their delivery of medical records, reports and progress notes to the billing staff.  I will never forget hearing about a particular provider who waited weeks to submit his records.  He literally drove around with stacks of medical records on the back floorboard of his car, turning them over to the billing staff only when so moved.

   Well, those days of lackadaisical nonchalance are over.  Medical groups should have a systematic process in place to get the medical record from the provider to the RCM team within 48 hours if at all possible.  Every day delayed in the dictation, completion and delivery of the record, increases the possibility of not getting paid.  Thankfully, the advent and ubiquity of electronic medical records (EMRs) has somewhat eased this problem.  Once the record is completed and uploaded into the EMR, billing staffs that have direct access to, or an allowed interface with, the EMR can bring the data into their systems and quickly get the claim out the door.

   Where an EMR is not in play, providers will need to find alternate ways to rapidly submit their medical records and reports.  For example, some anesthesia groups have designated baskets in each operating room, into which their anesthesia records are placed.  Someone on their staff comes by to retrieve the records at the end of the day or several times a day so they can begin entering the billing and coding data into the system as quickly as possible.

2. Verify Insurance Coverage Quickly.  The fact is many claims can be lost to timely filing issues because they were initially filed with the wrong insurance.  With the time window narrowing on Anthem claims, it is critical that your staff be equipped with the latest strategies and technologies to reduce incorrect insurance errors in the claim submission process.  Sometimes weeks go by before such errors are discovered, and then you are under the gun to determine the correct carrier and resubmit the claim.  Hospitals are in the primary position to receive and verify insurance and communicate corrected information once received.
3. Promptly Transmit Provider Changes.  Often, claims can be initially denied due to “wrong provider” errors.  To avoid costly delays due to such errors, groups—whether independent or employed—need to send their provider enrollment (PE) staff accurate credentialing information at the outset of a new provider’s tenure.  In addition, whenever there is a change in a provider’s location, name, status, etc., that information should be quickly communicated to your PE personnel so that they, in turn, can provide the new information to the payers, as required.
4. Schedule Regular Follow-up.  Make sure your billing staff is consistently vigilant in following up on claims submitted.  They cannot wait until the last minute to check the progress of the claim with the payer.  Some staffs may not follow up at all until they get a notice of denial due to untimely filing.  An automatic tickler system should be considered where an AR representative can be alerted to check with the payer after an assigned period of days has elapsed since the last action or communication.  Managers should hold these reps accountable, monitoring their success and failure rate as to the timely filing issue in particular.

When you have these strategies and capabilities in place, the concern over the compressed period to submit your Anthem claims should be significantly eased.  You can move ahead with confidence that the system you have implemented will, more often than not, secure appropriate reimbursement for services rendered.

No Time Like the Present

Realizing the increasing importance of expeditious submission and efficient follow-up of medical claims, this may be a good time for medical groups and healthcare facilities to consider outsourcing these critical tasks to proven experts.  We at MiraMed Global Services (MMGS) have been providing these services for 40 years and are an industry leader in RCM solutions.  We provide the expertise and careful attention to detail you deserve, and offer value-added services that smaller companies and internal billing staffs cannot.

With the stakes going up, and with ever-changing rules, you need a business partner you can fully rely on to get it right.  There is no time like the present to align your organization with a company that can do it all, and do it right.  The narrowing Anthem filing window is just one example of the many changes that constantly occur in the healthcare environment.  Let us put our proven processes to work for you.  If you are not already an MMGS client, please visit our website and see our full range of business solutions.