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.

Medical billing is a frustrating process for counsellors who are often juggling too many business tasks, as well as trying to provide excellent clinical care. In fact, many counselling practices collect less than 85% of the monies that they’re rightly owed from insurance companies. However, with good planning, and a smart billing staff (in house or otherwise), your practice can reasonably expect to collect between 96-99% of claims.

Insurance claim denials can be very inconvenient for patients and can affect a practice’s ability to receive payment for services rendered. Preventing insurance claim denials before they ever occur can help your practice to more efficiently receive moneys earned and to keep a better relationship with patients. Patients will be more likely to stay loyal to your office when their claims are routinely paid as expected. In order to prevent claim denials, it is best to understand some of the common reasons for them.

There are many reasons that claims can go unpaid, including:

Insurance Company Lost the Claim, and then the Claim Expired:  Sometimes insurance companies misplace claims. If a misplaced claim doesn’t make it into the insurance company’s system before the deadline, the claim will be denied. Frustrated providers might find themselves talking to someone from the insurance company who says, “even though the error might have been on our end, there’s nothing we can do. The time frame for filing has expired.”

Submitting Duplicate Claims: If a duplicate claim is filed before an insurance company has responded to the first claim, it may result in a claim denial. Multiple employees may also submit a claim if there is not an established procedure in place for claim filing. Having a system in place with claims tracking can help to avoid this common error.

You Provided Two Services in One Day: With behavioural health, insurance companies have a strict “one service per day” policy. This means that even if a patient is authorised for 12 sessions of therapy, if you provide two sessions in one day, you won’t be paid for the second session. Clinicians who provide group therapy, psychological testing, or medication reviews beware—sometimes these services also fall under the one service per day policy.

Incorrect Coding: ICD-10 has a lot of advantages over previous coding systems used for medical billing, but the volume of codes can get confusing. Implementing high quality medical billing software can help to ensure correct coding. Most systems will flag potential errors before allowing you to send claims, which may be very helpful in preventing denied claims.

Waited too Long to File the Claim: The vast majority of insurance companies allow 90 days from the time of service to file a claim. However, some insurance companies allow only 30 days to file (and a very few, such as Medicare, allow a year—wow). When claims are filed too long after the date of service, they are rejected.

Lack of proper authorisation: Insurance companies often require the patient to obtain preauthorization of services before treatment, especially for non-routine services like hospitalisations, surgeries and behavioural care. If you provide services without the proper authorization, the claim will likely be denied. To prevent this from happening, you can obtain pre-authorization from the insurance company on the patient’s behalf.

A pre-existing condition: Many insurance plans have a pre-existing condition exclusion clause. If they discover a claim has been submitted for treatment of a condition that existed before the insurance policy began, they will reject the claim. They might even deny a claim for a separate, new illness, if any other kind of pre-existing condition was not initially disclosed. This is usually because the insurance company would not have offered coverage in the first place if the patient had disclosed the pre-existing condition in the beginning.

These two common terms are Denied Claim and Rejected Claim. Both these terms are often used to discuss the medical billing claims and are also time and again used interchangeably. But, it is extremely important to understand that Rejected Medical Claims are very different from Denied Medical claims, yes they are not same. Today lets the different between a Denied and Rejected Claims in Medical Billing. Before we jump into that discussion, however, let’s review the difference between a rejected and denied claim.

A Rejected claim has been rejected because of errors. An insurance company might reject a claim because a medical billing specialist incorrectly input patient or insurance information. Rejected claims will not be processed because they are not considered to have been received by the insurance payer, and do not make it into the system. Once a medical billing specialist amends the errors on a rejected claim they can resubmit it for processing with an insurance company.

Reason for Rejected Claims:

1. Delay in Filing the Claim:

On a general basis the insurance companies allow a period of 60 to 90 days to file the claim from the time of service. But certain time when the claims are not filed within the stipulated period or long after the date of service, they end up getting rejected

2. Preauthorization / Authorization:

For many insurance plans preauthorization is a must. If the healthcare provider provides services without proper authorization the claims get rejected.

3. Patient Changes the Insurance Plan:

When a patient changes his or her insurance plan, the provider needs to network the new plan to the system and also get a new preauthorization done for the patient. If the provider fails to do so, the claims get rejected.

4. Lost Claim:

It doesn’t matter who replaced it, but if the claim gets misplaced and doesn’t make it to the insurance company’s system on time, the claim will be rejected.

A Denied claim is one that has been determined by an insurance company to be unpayable. Think of a Denied claim as the insurance saying ‘this claim has been sent for processing but has been denied for payment’. Claims are often denied because of common billing errors or missing information, but can also be denied based on patient coverage. Typically, insurance companies explain the reasons in the Explanation of Benefits (EOBs) attached to the claim.

Reason for Denied Claims:

There are plenty of reasons an insurer might deny your claims, but the most common billing errors are also the simplest and easiest to correct. Here are the top three:

1. Incorrect and/or incomplete patient identifier information(e.g., name spelled incorrectly; date of birth or soc. sec. number doesn’t match; subscriber number missing or invalid; insured group number missing or invalid)

Solution: Verify patient demographic and insurance information at EVERY visit. Ask permission to photocopy the patient’s state-issued identification (passport, driver’s license, etc.) and insurance card, so that you are sure to have the proper spelling, group numbers, etc., on hand.

2. Coverage Terminated:

Verifying insurance benefits prior to services being rendered can alert the medical office if the patient’s insurance coverage is active or has terminated. This will allow you to get more up-to-date insurance information or identify the patient as a self-pay.

3. Services Excluded or Non-covered:

Exclusions or non-covered services refer to certain medical office services that are excluded from the patient’s health insurance coverage. Patients will have to pay 100 percent for these services.

This is another reason why it is important to contact the patient’s insurance prior to services being rendered. It is poor customer service to bill a patient for non-covered charges without making them aware that they may be responsible for the charges prior to their procedure.

Causes of Medical Billing Errors:
Super bills that are difficult or impossible to read for the employee(s) responsible for entering the information into the practice management system. If the provider is not readily available to answer questions and clarify, sometime it’s up to the employee to determine.

Getting up-to-date patient info: When a patient checks in, that’s the time to ask if there are any insurance changes, address changes, etc. The front desk employees play an important roll in the reimbursement process.

Untrained or inexperienced employees: Many providers don’t see the need to pay well for the billing and coding functions. For this they get untrained and inexperienced employees who are not proficient on using the practice management software or the insurance claim process. Hiring more mature and experienced staff may cost a little more, but believe me it’s money well spent. And that’s true also for a healthcare billing service.

Charges are not posted: Many providers don’t realize the importance of posting insurance and patient payments for successful healthcare claim processing. If insurance payments are not posted, you can’t bill patients for the remaining uncovered yet eligible charges, copays, coinsurance, etc. Nor can secondary claims be created.

This adds up to a lot of money: A provider also doesn’t know how the practice is performing financially. Without posted payment information, you can’t run the reports necessary to show accounts receivable, outstanding claims, which insurance companies are paying, etc.

Preventing Errors:

There are many things a medical coder can do to prevent errors. A coder should always double-check a patient’s address, date of birth, medical record number, insurance ID and other identifying information, as well as ensure that all CPT and ICD-10 codes are correct. You should also verify that the diagnosis and treatment codes match.

Never skip steps like insurance verification. They are an important part of the process. You must carefully perform research in the chart and try to find all of the medical conditions that a provider has treated a patient for during the visit. Coders also need to ask for clarification when details aren’t clear, so that each condition is billed for appropriately and accurately.

Even when you’re sure you’ve done things right the first time, it’s always important to perform a double-check. Read through the claim and make sure there are no errors before you send it. This second check will often prevent you from making simple mistakes.

When it comes to confirming insurance coverage, make sure you get all of the necessary details. Some of the things you’ll need to know are:

• If the insurance company mandates Preauthorization.
• The co-pay and deductible.
• Limitations on visits and coverage.
• Maximum coverage for the particular procedure.
• The address claims should be sent to.