Move Stalled Claims Before Deadlines Disappear
Question: Our family practice has several unpaid commercial claims that have been in follow-up for more than 45 days. Some show “pending review” in the payer portal, while others have been denied or underpaid. At what point should we stop routine accounts receivable (A/R) follow-up and move the claim to reconsideration or appeal? Michigan Subscriber Answer: If you have information suggesting that the payer needs to change a decision instead of finishing processing the claim, then you should move the claim out of routine follow-up and into a reconsideration or appeal pathway. Routine follow-up is appropriate when the claim has not been adjudicated, the payer has no record of receiving it, the claim is suspended for ordinary processing, or the practice needs a status update, proof of receipt, or a missing-item request. In those cases, your team should document each instance of contact, confirm the payer’s expected processing time, and set a reminder to check in and follow up. Escalate to reconsideration or appeal when the payer has made an adverse determination or when repeated follow-up shows the claim is stalled beyond the payer’s normal processing window. Examples include a denial on the remittance advice, a payment that does not match the contract or fee schedule, a request to submit medical records after the claim has already been denied, a bundling or modifier decision the practice disputes, or a “no claim on file” response when you have timely filing confirmation. Note that some payers distinguish between a reconsideration, corrected claim, and formal appeal, so check the payer’s instructions before choosing the pathway. Going forward, you could build escalation rules into your A/R workflow instead of relying on staff judgment alone. Many practices establish internal escalation thresholds, such as follow-up at 30 days, supervisory review at 45 days, and appeal review at 60 days, while ensuring all actions occur within payer-specific filing and appeal deadlines. Waiting too long can turn an appealable claim into a write-off, even when the practice had a valid payment argument. If the payer denied or underpaid a clean claim, preserve the appeal window and submit the required reconsideration or appeal package with the remittance advice, original claim, supporting documentation, and a concise explanation of why payment is due. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC
