Simple Steps to Maximize Your Revenue: Getting the Claim There on Time!

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OB/GYN physicians work hard every day. Making sure you get paid what you are due is a critical success factor for all physician practices. In 2012, industry experts estimate that 30% of total medical revenue will be collected from patients due to the increasing dollar thresholds for patient deductibles.

OB/GYN physicians work hard every day. Making sure you get paid what you are due is a critical success factor for all physician practices. In 2012, industry experts estimate that 30% of total medical revenue will be collected from patients due to the increasing dollar thresholds for patient deductibles. That means that 70% of total medical revenue will come from your insurance plans which makes it very important that claims are received on time.

Sometimes in our efforts to improve our revenue cycle performance, we forget to pay attention to some of the basic foundations of physician billing – for example, getting the claim there on time! Make sure your OB/GYN practice has a Filing Limitations Guide which includes claim and appeal filing deadlines. These filing deadlines can be found on your payer’s website or provider manual. As you compile this information on each payer, pay attention to the specific wording each payer uses, such as calendar days, working days, within 12 months of date of service, or from date of remittance. Capture the filing time limits exactly as described in the payer’s website or provider manual. From this information, you can establish the turnaround time required by your medical group.

An example of a Filing Limitations Guide is shown below:

Payer
Claim Filing Limit
Appeal Filing Limit
Payer A
180 days from date of service
Within 30 days from the date of denial
Payer B
90 days from date of service
6 months from date of denial
Payer C
6 months from date of service
6 months from date of denial on explanation of payment
Payer D
9 months from date of service
60 days from date of last rejection
Payer E
Within 12 months of date of service
120 days from date of remittance
Payer F
180 calendars from date of service
90 working days from EOB


If a claim has been denied for “past filing limits,” you will want to confirm that. The date your claim went out is noted in your practice management system. If the denial is correct and you submitted the claim late, there is no further follow-up indicated and the balance should be written off with an appropriate adjustment code, for example “W/O claim filing limit.” This will allow you to quantify how often this happens and the dollar impact on the practice. Research needs to be done to determine why that claim (and others) is being delayed. Follow the path your claims take from charge entry all the way to the payer’s adjudication system. There are several stops along that path when claims might be delayed. The first delay may be from your claim editing or claim scrubber tools. The intent of these tools is to increase the accuracy and completeness of your claims. This is technology that your medical practice needs to have but review what happens when a claim hits one of those edits – how long does it sit until one of the staff corrects it and sends it on its way? The next potential delay could be the claim clearinghouse edits/rejections. Daily the medical practice should be receiving communication from their clearinghouse on the number of claims received and sent on to the payer and a list of those claims that were edited out – again follow-up is needed. And, of course the claim still needs to make it beyond any front end edits that the payer’s systems has in place. Until your claim has made it all the way into the payer’s adjudication system, your claim has not been ‘received’ and thus the filing limitations clock is still ticking.

If the denial is incorrect, it is important that an appeal be submitted timely. The clock starts ticking for denials based on how the appeal filing limit is defined. Notice in the Filing Limitation Guide above how variable the wording can be. It is very important that you have a dedicated staff to timely work denied claims or a rejected claim will time out and again bring no revenue to the OB/GYN practice.

Getting your claims to the payor on time is just one of many basic steps to maximizing your revenue cycle performance. Physician billing is really just a mix of many small steps that if done well consistently can have major impact to the OB/GYN practice’s bottom line.

Let us know in the comment box how you handle your claims.

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raanan meyer, md
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