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Clean claims are key to timely reimbursement, but be vigilant. (Practice Management Clinic).

Reimbursement is at least partially linked to your ability, or the ability of your billing service, to properly file and follow up on claim submissions. This installment of PRACTICE MANAGEMENT CLINIC focuses on reducing errors in this process.

Are your claims clean?

Filing clean claims should be a priority for everyone involved in the reimbursement process. There are myriad reasons claims are determined to be unclean. Here are nine common claims-data errors:

* Missing or invalid patient identification number or other patient information (sex, date of birth, etc.)

* Missing or invalid subscriber information (e.g., Social Security number)

* Lack of authorization or referral number

* Failure to check the assignment box

* Invalid dates of service

* Missing or invalid modifiers (updated yearly)

* Missing or invalid provider information

* Incorrect place of service (e.g., hospital vs office)

* Incorrect balance due

A clean claim has many definitions. In Oklahoma, for example, a law (formerly Senate Bill 192) that became effective on Nov. 1 defines a clean claim as one that has no defect or impropriety, including a lack of any required substantiating documentation, and an absence of any particular circumstance that requires special treatment that impedes prompt payment. The new law further uses language to create uniform prompt payment provisions under the various statutes governing third-party payments. It requires health plans regulated by the state's department of health to either pay or deny a claim or a portion of a claim within 45 calendar days. If the claim is judged to be unclean, the carrier must notify the person submitting the claim--in writing within 30 calendar days--which portion of the claim is causing the delay in processing. Overdue payments for clean claims will bear a simple interest at 10% annually.

What is our responsibility as providers? Claims should be submitted in a timely manner--that is, within 1 or 2 days of service. All claims should undergo carrier-specific edits before they are sent to carriers. Electronic claim submissions are strongly recommended over paper claim submissions for many reasons, but the best reason is that it is extremely difficult to prove that a paper claim was ever submitted to or received by a carrier.

In addition to the regular accounts-receivable monitoring your practice management software allows, it is imperative that your software--or your billing service's software--provides the technology to monitor clean claims that are not processed in a timely fashion. After all, what good is clean-claims legislation if no one ensures that carriers are complying with the statute? Check with your local medical society to determine whether clean-claims legislation exists in your state. And be sure to ascertain whether your practice management software provides the technology to notify you if your claims are not adjudicated in 17 to 30 (electronic) or 45 to 60 (paper) days. If it doesn't, it's time to investigate better management systems.
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Comment:Clean claims are key to timely reimbursement, but be vigilant. (Practice Management Clinic).
Author:Isenberg, Steven F.
Publication:Ear, Nose and Throat Journal
Article Type:Brief Article
Geographic Code:1USA
Date:Feb 1, 2002
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