By: Billie Mildenberger, Director of Audit Services
Issues Identified:
During a client’s quarterly billing audit, Lighthouse RCM Solutions identified a claim that was denied for timely filing and adjusted off as uncollectible.
Background:
Timely filing is the contracted timeframe in which a claim must be submitted to the payer. These deadlines vary by payer and the payer contract should outline the timely filing limit for claims and appeals. When a claim is denied for timely filing, it is important to remember you may appeal the denial. To appeal you will need to submit documentation to support that the claim was sent and received within the timely filing limit. Filing claims and appeals within the payer’s contracted time limit is key to avoid timely filling denials.
Billers and revenue cycle management teams need to keep in mind that most people responsible for processing appeals are not medically trained, so it must be made explicitly clear in the appeal why the claim should be paid.
Potential Impact:
If the quarterly audit sampling represents issues that are repetitive throughout the year, the potential revenue loss could exceed well over $50,000. However, routine billing audits allowed us to identify this issue before its impact could become more widespread.
Resolution:
Timely filing denials are preventable and appealable. It is important to trend timely filing denials and monitor aging reports to prevent these issues.
Why do we audit?
Lighthouse RCM Solutions completes a quarterly audit for all of our full-scope clients to ensure that processes are tight, well defined, and effectively communicated.
Our audit process includes a thorough analysis of the revenue cycle, from charge capture to 100% adjudication (either payment, adjustment, or write off) – determining if the process to 100% adjudication is not only done correctly from an accounting standpoint, but compliantly.
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