Clean Claim Laws and Medical Billing

Clean Claim Laws and Medical Billing

Clean claim laws, which are state specific, are designed to make sure that practitioners receive reimbursements from payers in a timely fashion. Each state has passed its own version of the clean claim law. Some, such as those in Texas, levy heavy penalties on those insurers who delay payments when a clean claim is submitted, while other states, such as South Dakota, do very little to penalize payers. Usually under clean claims a payer has 30 days to turn a claim around.

Utilizing Clean Claims

If your medical billing and coding personnel or company is going to properly utilize your state’s clean claims law, then they are going to have to properly track all claims. Also, there must be a medical billing servicesystem in place for those claims that payers do not address in a prompt and efficient manner. In order to do so, you’re medical coding and billing specialists will need to know and address the following aspects related to the process.

First, they’ll have to know which insurance companies are covered by your state’s clean claim law. The fact is some may be exempt. Your company will need to track when the claim was submitted and what instances stop the clock that pertains to your claim. That may include a request for more information or clarification regarding some aspect of the claim.

After you respond to any requests, you’ll need to continue to track the claim. Once the final decision is made, it’s important that your billing office or company be able to determine quickly if payment processing conformed to the clean claim law. If it did not, a claim may be filed against the payer.

Test Run

One way to get a handle on what payers are habitually late in processing payments is to track a small number of such claims to see what percentage may be late. If you find a high percentage of claims are late and not conforming to the law, you can then begin carefully tracking each one and take appropriate action regarding those payers that are not following the law.

System in Place

It’s essential that your medical coding and billing professionals have a system in place that ably tracks each claim in relationship to the state’s clean claim law. Making sure that payers follow the law allows your practice to receive timely reimbursements, keeping your practice fiscally healthy.

Of course, having a reputation for submitting clean claims is important. If a payer finds that your claims are consistently problematic because they have not been properly scrubbed, then you will have a hard time invoking the clean claim law in your state. Complete processing, data entry, and accurate documentation will go a long way to ensuring that your billing conforms to your state’s clean claim law.


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