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Reasons for a Delay in Medical Reimbursement Payments

Once a provider has rendered a service, the goal is to receive reimbursement, or payment, as quickly as possible. Many factors influence the receipt of a provider's payment, and some things can cause a delay in those reimbursements. If there is a delay in payment, the reason can be researched and, in some cases, a solution can be found.

  1. HCFA-1500

    • The Health Care Financing Administration (HCFA), in part, is responsible for streamlining practices to make the submission of medical claims easier. According to her textbook "A Guide to Health Insurance Billing," Marie Moisio writes that the HCFA-1500 is a "standardized form used to submit health insurance claims." Most outpatient billing is done on this form, and even small errors can cause rejection or delay of claims. Some common errors include using the wrong Social Security number or date of birth for the patient, selecting the wrong gender or incorrectly typing the patient's insurance identification number.

    Unmatched Codes

    • A procedure code refers to what was done to a patient, and a diagnosis code explains why. For example, If a patient came into the office complaining of back pain, then had an X-ray, the patient correctly would be charged for an office visit and an X-ray. If the patient complained of back pain and was billed for an office visit and knee surgery, the insurance company would likely delay processing or reject the claim because the codes for back pain and knee surgery don't match.

      The same is true of gender. If it is documented that a male patient is being charged for abnormal uterine bleeding, the claim wouldn't be processed because men don't have menstrual cycles. The office personnel must fix this error if the insurance company is to consider paying.

    Prior Authorization

    • Before some procedures, the doctor's office must ask the insurance company for permission. If permission is not granted in advance, the insurance company can refuse to pay. In some cases, the office staff or the patient can appeal the decision. For example, an appendectomy usually requires permission from the insurance company. If an office staffer types a letter to the insurance company stating that the patient came into the hospital in pain, and the surgery had to be performed under emergency circumstances, the insurance company would probably reconsider and pay the claim.

    Medical Necessity

    • Personnel at insurance companies can also decide a service is not medically necessary. If a patient complains of a sore right arm, a doctor might want to order a CT scan of that arm. The insurance company, however, will suggest that only an X-ray is necessary. Normally, if the doctor continues with the CT scan, the patient will be responsible for payment. The doctor could, however, write a letter explaining that X-rays have already been done and detailing why a CT scan is better. Although it will cause a delay, there is a chance the scan will be paid.

    Pre-existing Conditions

    • A pre-existing condition, according to Moisio, is a medical problem a person had "prior to implementation of the insurance policy." Insurance companies often won't pay for pre-existing conditions. Again, medical office personnel could contact the insurance company to find out about exceptions to the rule. Even if payment is delayed, it is better than not receiving it at all.

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