Clean Claim Laws: Tough To Master But Worth The Effort

All 50 states currently have a Clean Claim Law. The effectiveness of the laws varies dramatically ranging from South Dakota which provides for no financial penalty to Texas where the penalty can go up to a requirement on the payer to pay billed charges; that’s right billed charges.

Clean Claim laws can be a powerful medical billing tool because they are built upon the concept that insurance companies have a responsibility to quickly adjudicate clean claims. The typical law provides 30 days for a payer to process a clean electronic claim. To properly benefit from Clean Claim laws a medical billing company or medical practice must be capable of reliably and systematically keeping track of:

1. To which insurance companies does your state’s clean claim law apply (some payers are exempt);

2. When a claim was submitted,

3. When a request for information was received from the payer (if you receive one then it stops the 30 day clock until you respond),

4. When your office responded to the information request (this starts the 30 day clock again), and

5. When you received a payment or denial.

Planning and constructing the monitoring system can be difficult, but it can have a significant impact on how quickly your claims are paid cleanly. Aggressive users of clean claim laws have actually received calls from payers assuring them that their claims will be process quickly and requesting that complaints be held to give the payer a chance to prove itself.

A quick way to get started with using the clean claim law is to pick a specific payer that you believe habitually delays claims beyond 30 days. Find a handful of claims that have gone past 30 days and then test the water with those claims. This will allow you to learn the basics of using the on-line tool provided for submitting complaints and see the impact of your initial complaints.

Copyright 2006 by Carl Mays II

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