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.

DME Billing Solution

It is a known fact that DME providers are already facing a lot of problems with the increasing confusion in insurance benefits and medical claims. A synchronized effort with the right design, transformation process with the help of intelligent revenue cycle management processes that adapt well with the market realities is the need of the hour!

Impact of Medicare DME Reprocessing Claims

DME providers need to be more aware of the massive change that CMS has implemented impacting over 36,000 claims each day for a total of 24 weeks. The 21st century Cures Act (CR9968) is now responsible for the CMS conducting adjustments for fee amounts for certain DME competitive bid items with claim dates of services July 1 2016- December 31st 2016.

During this six month period, providers were paid less for their services, and now are being reimbursed slightly more based on the new fee schedule amounts. Depending on the jurisdiction you fall under will depend on how fast the claims are being reprocessed.

For jurisdiction D, all claims were reprocessed within 9 weeks. This sounds great to be paid more money for your services, but this creates many new issues that the provider now has to manage.

How do I know if the claim is reprocessed? 

DME claims that are getting reprocessed will have a code of N689. At this point of time, the provider will need to look at their A/R and it will show a negative balance on your records. You will need to adjust this claim so that is higher your DSO!

The key areas with the Physician signature, documentation, coding practices, dispensing of the DME equipment, eligibility verification and authorization process with the patients has to be a streamlined effort.

Evaluate options for secondary insurance and patient pay

With the claims being well over one-year old at this point, it is likely that the balance is paid off and the claim is resolved. Now with the new fee schedule amounts, this will create the issue of claims being sent to secondary insurance or if the patient doesn’t have a secondary insurance, it will show the patient has a balance now with a low dollar amount or even pennies remaining they owe you.

Since these amounts are low, it may be in the best interest of the provider to not bill the patient for the meager balance and keep this balance on file, and when the balance gets to $5.00 or higher they can send an invoice. If you send an invoice now for a small balance, this will cause further confusion with the patient when they won’t recall the services that were provided one year ago.

Caution on over payment concerns

CMS has mentioned on their website that when they are reprocessing the claims, there is a likeliness of an over payment. This is due to patients that are in a SNF, HHH, etc. for the date of service on the claim. In this case the provider will receive an over payment demand letter. Even though this is time-consuming, it is in the best interest of the provider to send any over payment amount back to CMS to avoid further issues down the road.

KE Modifier

If your claims required a KE modifier, you have to appeal your claim with specific guidelines. Use a reopening request form to submit for these specific claims

Get in touch with our experts and be assured of a comprehensive assistance program in DME billing as we will be working as your reliable operational extension! To help manage your DME billing and collections, Learn how you can lower DSO, reduce bad debt, and grow your AR with our experts!