We traced a stack of Medicare claims for a practice last month, one by one, because the balance made no sense. Medicare pays clean claims on a schedule set by law, usually inside 30 days, and owes interest when it runs late. This practice had $164,000 sitting with Medicare past 60 days. One of those two facts had to give.
Why are my Medicare claims not being paid?
Usually because they never arrived: rejected at the clearinghouse, waiting on paper that was never mailed, or lost between systems. Medicare pays clean claims on a legal clock, so old balances point at your own pipeline first.
What tracing actually means
Nothing fancy. You pull each claim and check three things. Does our system say it was billed? Does the clearinghouse, the postal service that carries claims to insurers, say it was accepted? Does Medicare say it was received? Three yes-or-no questions per claim. Tedious, simple, and worth every minute.
The whole trace lived in one spreadsheet: claim number, the three checkpoints, and a column for what we found. Two afternoons of unglamorous work. By the second afternoon the pattern was already obvious, because failures at this stage aren’t creative. The same three or four breaks repeat down the whole list.
What we found
For roughly a third of the claims, Medicare had no record of them at all. Billed status in the software. No journey in the world.
Some had bounced at the clearinghouse for mechanical reasons, a bad ID number, a missing field. Those are rejections, and a rejection is different from a denial in a way that matters. A denial means the insurer looked at your claim and said no. A rejection means nobody ever looked. It bounced at the front door. Rejections land in a different queue than denials, sometimes in a report nobody reads, and here’s the trap: in your system, a rejected claim still looks submitted. It sits in the balance, aging politely, and it was never in line to be paid.
Others needed paper. A few payers and claim types still do, and that opens a gap between two very different things: billed, which is a status your software sets, and mailed, which is something that happens in the physical world. Some of these claims had carried a billed status for months while the paper form they needed was never printed. That failure has a whole biography of its own.
Why a prompt payer is the best test you own
With a commercial insurer, slow payment has a dozen possible explanations, and you can spend a month arguing about which one applies. With a payer on a legal clock, the explanations collapse to one side of the pipe: yours. That makes a government payer’s aging the cleanest instrument in your building. It’s a free, always-running test of whether your own claims pipeline works, and most practices never read it that way. When Medicare carries your balance, the problem isn’t Medicare.
The part that makes it urgent
Government filing windows don’t negotiate. Past the deadline, a claim converts from money you’re owed to money that’s gone, quietly, with its billed status intact. Nothing announces it. The balance just gets a little more fictional.
There’s one more tell hiding in plain sight. Medicare pays interest when it runs past the clock on a clean claim. So an old Medicare balance with no interest arriving is telling you something specific: the claim isn’t late. It’s lost, or it’s broken, or it never showed up. Late claims earn interest. Missing ones earn silence.
Medicaid runs on a clock too
Everything above applies to the other government payer, with one wrinkle worth knowing. State Medicaid programs carry prompt-pay rules of their own, and the windows vary by state, but the mirror property is identical: a clean claim gets paid on a schedule, so an aging Medicaid balance points back at your own pipeline first. The wrinkle is managed care. Many states hire private insurers to run Medicaid day to day, and those plans pay on contractual clocks instead of the state’s statute. A Medicaid balance often turns out to be a managed-care balance wearing a government label, which changes who you call and which clock applies. Split the two before you work the list, or you’ll spend the morning arguing with the wrong office.
What we found, what we fixed, what holds
Found: $164,000 aging with a payer that pays on a legal clock, and a third of it never received on the payer’s side at all.
Fixed: a submission trail for every claim, three checkpoints long. Built in the system. Accepted by the clearinghouse. Acknowledged by the insurer. Every claim missing a checkpoint got worked until it had one, and the paper claims got printed, mailed, and logged for real.
Holds: any claim without an insurer acknowledgment inside a set number of days flags itself. And prompt payers carry a standing rule now: a balance older than their legal clock triggers an investigation that starts on our side of the pipe, not theirs.
Try it on your own numbers
Pull your balances for Medicare and Medicaid only. Take everything older than 45 days and ask one question per claim: can anyone show me proof the insurer acknowledged receiving it? Every claim without an answer may never have left the building. If the balance turns out to be broader than government payers, the elimination sequence finds which step is leaking.
We’ll trace your government-payer balances claim by claim and show you which ones the payer has never seen. Grab 30 minutes with us. Prep nothing.