Claims Transmission on Hold

Posted by Deepak Sanghi on March 5th, 2016

It is that time of the year when Practices and healthcare billing solution providers begin to release claims that they have kept on hold for more than a month.  While this practice of keeping claims on hold may come as a surprise, especially with the shortened filing limits of Payers and the inevitable delay in cash flows, there is some logic in keeping the claims on hold.  Let us discuss a few of those reasons below:

New Coverage period:  With the New Year, most people in the US would have entered a new coverage period, since most Plans offer a Calendar year based coverage.  With the new coverage, the Deductibles are also re-set, which is one of the main reasons for medical claims processing entities to keep these claims on hold and not transmitting it to the Payers.

What is Deductible?  Each payer has a fixed amount that the member has to bear upfront, before the Insurance coverage would start.   This fixed amount not only varies by Payer, but also for different Plans offered by the same Payer.  In general, Plans with higher Premiums will have a lower Deductible.  Deductible is different from Copay; Copays are to be paid by the Patient throughout the year during every visit to the Doctor, while Deductible is only till the fixed amount is met, after which the Payer will commence payments.

Why hold claims?  With the new coverage period commencing from 1^st January for most patients or beneficiaries, they would have still not met their Deductibles before mid-Feb.  If the medical billing solutions provider transmits the claims during this period, the probability of adjustment towards the Deductible by the Payer is very high.  This would then need follow-up with Patients to make them pay the Provider or Hospital. If the claims are on hold for a few weeks, many patients would have met their Deductible with other Providers or Facilities, resulting in payments from the Insurance.  It is a game of ‘cat and mouse’ that could either pay-off or not.

It should be remembered that not all patients would have met their Deductibles before February or March.  Holding the claims beyond March has its own set of risks, like crossing the Timely Filing limit (TFL) of some Payers.  The medical claims processing entity is only trying to minimize the number of claims that will get adjusted in this category.

Insurance Eligibility Verification:  One of the primary and easiest ways to avoid keeping claims on hold for the above reasons is to do Insurance Eligibility Verification.  Verifying eligibility and Benefits will give a clear picture of the Deductible and the quantum that is utilized.  This way the Provider or Facility can let the patient know the amount that they would need to pay and collect it upfront before rendering services.  Insurance Eligibility Verification not only provides information on Deductibles, but also Copays, Co-insurance if any and any other coverage details.

About e-care India:

e-care India is one of the pioneering medical billing companies in India that promises the above mentioned benefits with total customer satisfaction. With 16 years of experience in the industry, e-care’s 3 medical claims processing delivery centers have been providing end-to-end healthcare billing solutions including Insurance Eligibility verification seamlessly to its clients. To know more about e-care and its services, log on to www.ecareindia.com