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MEDICAL BILLING BLOG

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What Payers Don't Want You To Know About Clean Claim Laws

  
  
  
  
  

medical billing clean claim law Each state has passed a Clean Claim Law. The level of benefit these laws provide to medical practices and facilities starts on the low end with states such as South Dakota that provide little more than a slap on the insurance company's wrist to states such as Texas which levy substantial financial penalties on tardy payers.

The basic idea of the law is that a payer has to respond to a clean claim within a set time (usually around 30 days for electronic claims). In order to utilize the clean claim law effectively you must have a tracking system built into your medical billing process that flags:

  • To which insurance companies does your state's clean claim law apply (some payers are exempt);
  • The date your practice initially submits each medical claim;
  • Events that stop the clean claim clock (e.g., an information request from the payer),
  • When your practice has taken actions in response to payer requests;
  • The date when you received the payer's final adjudication decision.

The idea of systematically tracking all of this information may be daunting, but with a smart system design it is possible and most definitely a worthwhile undertaking. After submitting a few Clean Claim law violation reports you will see your claims pay faster. I have seen situations where payers have actually called just to assure the practice that claims will be quickly processed.

One way to quickly get started using the clean claim law is to run a trial on a payer that you feel consistently takes more than 30 days to ajudicates claims. Find a small number of large claims for this payer that have gone past 30 days and then conduct a trial run with those claims. This will allow you to learn the fundamentals of how to submit and monitor complaints and see the results of your complaints.

Copyright 2006 by ClaimCare Medical Billing Services

Medical Billing Services Must Utilize Scrubbers

  
  
  
  
  

One of the most important things in billing is to create and follow a very structured plan that can be measured each step of the way. Remember, if it cannot be measured and monitored it cannot be improved!

Clean claim submission can reduce average days in AR to less than 45 days

claim scrubbingThe leading medical billing services operations utilize scrubbers that ensure your claims are clean before they are submitted to payers. These scrubs accelerate the speed of collections by avoiding denials and delays. They also increase collections by minimizing the volume of "re-work" and allowing billing staff to focus their efforts on pursuing true collections improvement opportunities and not simply resubmitting claims that should have been paid the first time. As a result of these scrubbers, over 90% of claims submitted are paid upon first submission. These "scrubbers" include:

  • Basic mechanical scrubber that assures that all claim fields have been properly filled with formatted data (social security number with 9 digits, date of birth etc), the NPI is in a proper field, there is a referring physician if needed, etc.
  • Scrubber that checks coding, bundling, and procedure information versus local Medicare and CCI rules. This scrub assures better coding, identifies overlooked procedures or codes.

The truly great medical billing specialists can rely on medical billing specific know-how and business intelligence created over time through work with many medical practices and facilities in the given payer relevant geographic area.

  • Dynamic Proprietary Rule scrubber that checks for optimal coding and documentation versus the particular payer or plan's rules. This scrub assures that each claim is optimized for clean submission. When the payer or plan's rules change or when the billing office detects a systemic issue they can update the scrubber to filter and fix problems before claims go out. These specialized scrubbers can make a significant collections difference.

At ClaimCare Medical Billing Services we have found that these actions can decrease the medical practice's collections cycle by up to 40-50 days. This is why you need to insure this critical step is being completed no matter who is doing your Medical Billing.

Copyright 2008 by Carl Mays II

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