The law’s main premise is that a payer must reply to a valid claim within a certain amount of time (usually around 30 days for electronic claims).

In order to efficiently use the clean claim rule, your medical billing process must have a tracking system that flags:

• Which insurance firms are covered by your state’s clean claim statute (some are exempt)?
• The date on which your clinic submits each medical claim for the first time;
• Events that bring the clean claim clock to a halt (e.g., an information request from the payer),
• When your practice has responded to payer requests by taking action;
• The date on which you received the final adjudication decision from the payer.

The prospect of carefully tracking all of this data may seem intimidating, but with the right system architecture, it is both achievable and desirable. Your claims will pay faster after you file a few Clean Claim law violation reports. I’ve witnessed cases when payers have contacted solely to reassure the practitioner that claims will be processed swiftly.

Running a trial on a payer that frequently takes more than 30 days to adjudicate claims is one method to quickly get started using the clean claim law. Find a small number of significant claims for this payer that have been open for more than 30 days and run a test with them. This will enable you to understand the foundations of how to file, monitor, and view the results of complaints.

Tips for Getting Your Medical Practice to Have a 95% Clean Claims Rate

How can your medical practice attain a clean claims rate of 95%? Despite the fact that this may appear to be a tall goal, there are several medical billing tactics your medical practice may apply to help increase your clean claims rate – and your entire revenue cycle management!

Keep patient records up to date.

There’s a lot of patient information that can change—and change quickly—from contact information to insurance carriers and more. Patients must check or update their current information before getting treatment, as faulty patient data is a leading source of denied claims. To reduce delays, use exact documentation to help check patient information ahead of time, and have patients update their paperwork at every visit (or even sooner with automated reminders).

Prior to the date of service, double-check your eligibility.

Patients that come to your office on a regular basis are known as established patients. They’re also the patients who your employees might presume haven’t had any recent insurance changes. Most denied claims, however, are generally the result of outdated established patient insurance information. Collecting and confirming every patient’s primary, secondary, and even tertiary insurance at least five days before their scheduled service is one step toward a 95 percent clean claims rate.

It’s also vital to double-check any in- or out-of-network benefits, copays, or deductibles.

Keep in mind the deadlines for filing insurance claims.

In most cases, filing a claim necessitates submitting it within a specific time frame. Any claim submitted outside of the window will result in a higher number of refused claims.

 If you want your practice to have a near-perfect clean claim ratio, one of the best ways to do so is to pay attention to claim deadlines and handle any concerns with patient coverage prior to their date of service so the claim is not submitted late. Aim for authorization between three and five days prior to service as a best practice.

Even the cleanest, most well-documented claim can often take weeks, if not months, to process. In the meantime, the practice loses out on revenue. This is why many of them opt to have their billing handled by a third party. Ultimately, WWS contributes to a smooth, continuous flow of revenue that benefits the bottom line of health practices. Contact WWS today to learn more.

HME businesses face increasing numbers of pre- and post-payment audits, which can be very stressful and costly events. Without a sound strategy for maintaining accurate and retrievable documentation, an audit request can disrupt operations and put your organization at financial risk.

When an audit strikes, the response must be swift and precise. The best approach to an audit letter is a quick response with proof that all documentation complies with requirements.

Five steps HME providers can take to give a speedy response and make sure all claims are audit-ready include:

1. Give Customer Service Representatives tools to improve intake:

• Knowledgeable customer service representatives at the front end are essential to collecting the right information at the start of service, but staff turnover and constantly changing requirements make it difficult to keep CSRs up-to-date on payer requirements.
• Technology can fill the knowledge gap if it does more than just park the data in a form prompting CSRs to collect specific documentation, which enables correction of the claim before it is filed.

2. Document to payer-specific rules:

• Improve efficiency by helping CSRs collect payer-specific requirements through established validation rules.
• While Medicare rules may call for a document to support specific Healthcare Common Procedure Coding System (HCPCS) codes, other payers may have a looser set of rules for that procedural code, which don’t require the same level of documentation saving time for the CSR.

3. Enable quick response to the audit letter:

• Staff should be able to quickly access the documentation when responding to an audit letter, which is not always easy in the case of long-term service.
• Establishing a link between billing records and the sales order documentation eliminates the risk of error when pulling documentation and ensures the information can be gathered efficiently.
• In addition, advanced HME systems allow users to collect, submit and track documentation electronically in response to CMS audits.

4. Automate document review within the workflow:

• There are times a critically needed product must be delivered before documentation is complete.
• This increases the need for a careful documentation review before submission of the claim to ensure progress notes support medical need and meet requirements.
• HME providers can easily determine whether or not to delay confirmation of a claim until the file is complete and the claim is substantiated by automating the review process throughout the workflow, utilizing optical character recognition technology and installing checkpoints that alert staff to missing or inaccurate information.

5. Capture data on all patient-care related interactions:

• Setting up a process to capture all telephone calls to patients, verbal orders from physicians or communication with other providers is critical, but difficult with the number of people involved in each case.
• Technology that documents actions by time, date and personnel involved provides additional support as an HME provider demonstrates compliance with billing requirements.

There’s no sure way to guarantee you won’t go through an audit; however, by ensuring the good HME business technology is in place you can take on most any audit challenge. With proactive compliance and timely response submission, audits can be resolved and claims are paid faster leading to improved cash flow.

Don’t wait for an audit Make every claim audit-proof from the start and For more information email us at support@wonderws.com