What’s a held claim?Held claims are claims that, for some reason or another, need to be manually processed by an MSP adjudicator. Unfortunately, when your claim is being held, MSP doesn’t tell you why or if there’s even anything wrong with the claim, just that it needs to be manually reviewed.
How long do MSP Claims get Delayed for?There are millions of claims submitted per month, and after being held, a claim must be reviewed by a real person. As you can presume, this might take awhile. Once an MSP adjudicator gets to your claim then will review it and determine whether the claim will be adjusted, released or denied. Again, as you can imagine, this takes a lot of time. Ultimately, this means the on hold time is determined by MSPs volume and staffing. While MSP likes to have claims processed within 30 days, this is often not the case. You can expect for it to regularly take much longer – MSP can hold a claim for up to 18 months, but we find that they normally do not hold any claims longer than 6 months. Processing times may also vary throughout the year due to staff shortages, holiday periods, new graduate classes starting and annual renewals. Since MSP tends to receive a large influx of claims at these times it’s only normal that this would slow down the manual review process.
Why are my MSP claims being held?MSP will not release details as to why your claim is on hold until after they have finished processing it. Even if you call MSP, they cannot release these details. Even if you ask your billing service or any billing agents you’re working with, MSP can still not release any details. A held claim will just sit as held until a real person has the time to review and check it.
5 Common Situations that Delay MSP ClaimsThere are a variety of reasons why MSP claims are held, and it's not always necessarily anything that is within your control. However, over the years, as our team has helped doctors submit over $50,000,000 worth of claims, we’ve noticed at least 5 common reasons why MSP claims are being held.
1. Multiple procedures billed on the same dayIf you have multiple procedures billed on the same day, your MSP claim might be held because they need to be reviewed and approved in order to make sure that everything you’ve claimed is accurate and correct.
2. Continuing Care from Previous Patient (CCFPP)If you’ve added the continuing care premium to your claim it might be held until the initial call out has been paid. Remember that a call out premium is eligible when you are called from outside of the hospital to come and care for a patient. Then, if you continue to see additional patients you would be entitled to bill continuing care premium for each 30 minutes after the initial 30 minutes you spent with the patient you were initially called to see. Sometimes the continuing care premium gets held because the call out just hasn’t been processed yet. These claims may also be held until the initial call out has been paid, and may require more than one resubmission as a result.
3. Critical Care fee Codes billed with Call OutsSometimes, you may have added a call out premium to a critical care fee code. However, some critical care fee codes that are billed do not permit call outs as it is deemed included. Therefore the rules need to be double-checked by an MSP adjudicator to see if it’s eligible.
4. The Claim note is longer than 20 charactersAny claim where the note is longer than 20 characters cannot be read electronically by MSP. Therefore, the claim is automatically dropped into manual review so that a MSP adjudicator can read the note.
5. New Physicians/New BillersLastly, we find that with all new physicians, or at least those who are new to FFS Billing, tend to have more held claims than a seasoned practitioner. Typically this is so that MSP can review your billing patterns and look at the different types of claims being billed. Don’t worry, this is standard and it tends to resolve within a short amount of time.
ConclusionWe know that having your claims held can be frustrating, but ultimately, if this happens there’s nothing you’ll be able to do but wait. Having a held claim doesn’t mean your claim is rejected or that you’ll never get paid for it. Typically it just means a delay in your pay. If you are getting a lot of held claims, reach out to your billing agent and ask them to see if they notice a pattern or can shed any light as to why so many of your claims are being held. If you want to look on the bright side, at least they haven’t been rejected or paid with an adjustment, while there are tips to avoid rejections, there’s not as many to avoid held claims. That being said, remember the 5 common reasons listed above and don’t stress over when it’s going to get paid. If MSP requires any extra information, they’ll get in touch. We hope this sheds some light as to how the process works and what you can expect. This article offers general information only and is not intended as legal, financial or other professional advice. A professional advisor should be consulted regarding your specific situation. While information presented is believed to be factual and current, its accuracy is not guaranteed and it should not be regarded as a complete analysis of the subjects discussed. All expressions of opinion reflect the judgment of the author(s) as of the date of publication and are subject to change. No endorsement of any third parties or their advice, opinions, information, products or services is expressly given or implied by RBC Ventures Inc. or its affiliates.
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