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Outstanding Claims Management

This document will explain how to sort through outstanding claims in MacPractice and follow up with the payers as necessary.

Clean Up Outstanding Claims
First, it is important to determine which claims truly need to be paid on, and which were in fact paid, but not marked as Paid/Closed in MacPractice. It will make it easier to manage your truly outstanding claims if you find these claims that should be closed, and close them. A claim will only be closed automatically at time of payment if payment information is entered for every procedure on the claim (even if that is simply a 0.00 payment). Therefore, if an insurance company does not pay on a given procedure, the claim may not be closed by MacPractice automatically, depending on your method of data entry.
 
To find claims that are paid, but still marked as Outstanding, go to the Managers ability, then select the Claim Manager node in the sidebar. Expand the node, and select Outstanding Claims. Leave all filters as defaulted, because you want to see all claims, and click Apply. If you have a lot of outstanding claims, this may take a few minutes to run.
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Eventually you will see a list of all the claims that are outstanding in your system. If they are highlighted in red, do not be alarmed. Please see our documentation on Timely Filing Limits for more information on why they are highlighted. Within Claims Manager, when you click on a claim, the lower portion of the window will show you the details of that claim. In the lower right corner, you will see a Claim Detail area. If the Total Unpaid amount is 0.00 or dramatically lower than the Total Fee Amount, that indicates a payment has probably been made on this claim. To the left of the Claim Detail area is a list of the charges on the claim. The far right column in this table displays the amount unpaid for each charge, which may help you further establish whether or not the claim was paid.
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If you wish to view a claim in more detail, click the View in Ledger button. This will take you to this patient's ledger, and highlight the claim in question. Confirm that there is already an insurance payment tied to this claim, then highlight the claim in the ledger and go to the Other menu and select Set Claim Status Paid/Closed to manually close out this claim.
 
There is a database utility you can use to set all claims with a remaining 0.00 balance to Paid/Closed, but this should be used with caution.
 
While there may be a large number of these outstanding claims, combing through your claims and closing those that need to be closed will make the rest of your claims management process much easier.

Follow Up on Outstanding Claims
Once you have narrowed down your outstanding claims to include only those that are actually unpaid, you can use the Outstanding Claims Manager to help organize your remaining claims. Run the manager with only a few insurance companies selected, or click the Ins Carrier column header to sort the list by payer. This way, you can easily see which companies have the most outstanding claims, and deal with them appropriately.

General Information
Call the payer to determine if there are any problems with how you are sending their claims. If you have a particular carrier where it seems as though none of your claims ever got through to them, it is possible that those claims were billed incorrectly. For example: perhaps they have your group information on file, and you billed as an individual; maybe the claims are missing an ID number, or have the wrong Tax ID on them. There are many things that could be wrong on any given claim, so your first priority would be to find out what this payer has on file for the doctor - what NPI should be used to bill the claim, what Tax ID, and so on.

If you notice that you have a lot of outstanding claims for a given carrier, but all of them are before a certain date, it is possible that there was an issue, but it has already been fixed. These claims you might be able to rebuild and/or resubmit immediately without making any changes.

If you come across claims that you are unable to figure out on your own, or if you start noticing general patterns (such as payers that never pay, patients that never get paid on, and so on) please contact MacPractice Support for assistance.

Paper Claims
Any time you submit a claim on paper, unless it is lost in the mail or something like that, it was almost certainly adjudicated manually. This means that you should receive an EOB stating that the claim was denied, as well as the reason why. For paper claims, you can review the EOBs on record to follow up on why the remaining claims were unpaid. If you do not have copies of this information, you should be able to call the payer and either get more information on the claim, or have them resend the original EOB.

eClaims
eClaims are not always adjudicated manually (that is, they are filtered by a computer before they are officially processed). If, during the automated editing process, they are found to have problems, the payers are fully within their rights (according to the HIPAA specifications on eClaims) to simply delete these claims from their front-end system. Unfortunately, they are not required to send a rejection back to you in any form, meaning that the claims simply disappear. In other words, you will call the payer to request information about these claims and will be told that they were not received. This is because the customer/provider services representatives at the insurance companies do not have access to this front-end system - they only see claims that made it past that step.

Many payers will send back rejection messages. When a rejection message is received, MacPractice will send the claims to the Rejected bin in the eClaims ability. If a rejection reason was included, this will be attached to the claim. However, this is an optional service for the payer. Some payers will not send rejection messages, meaning the claims will simply sit in the "Accepted" bin indefinitely.

This means it is your practice's responsibility to follow up with claims when you do not receive a remittance within a reasonable amount of time. The MacPractice EDI Department is more than happy to assist with any specific issues that you come across, but there is no way for us to track your claims. Contact the MacPractice EDI Department to research a claim within 10-15 days of submitting the claim. The front-end system purges the claim after 30 days and the reason for claim deletion will no longer be accessible.

Timely Filing Issues
If you find eClaims that you cannot see any problems with, and can be resubmitted, but the carrier's timely filing deadline has elapsed, you will need to print a Timely Filing Letter via Capario's web portal (Note: You must have Capario Premium Portal to generate these letters. If you do not have this service, MacPractice Support can generate the letters for you, at the cost of $25/letter). This letter will supply a form of proof that the claim was submitted within their timely filing limit, provided it was originally submitted before the deadline elapsed. For more information on creating Timely Filing documents in Capario Portal, please click here.

For paper claims, you can generate an insurance tracer, but these are less-frequently accepted as a valid proof of timely filing.
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