All 50 states currently have a Clean Claim Law. The effectiveness of the laws varies dramatically ranging from South Dakota which provides for no financial penalty to Texas where the penalty can go up to a requirement on the payer to pay billed charges; that’s right billed charges.

The fundamental concept behind Clean Claim Laws is that insurance companies must respond to a clean claim within a given period (typically 30 days for electronic claims). Systematic utilization of these laws will allow a medical billing service or medical practice to significantly accelerate and increase collections. In order to take advantage of the clean claim law one must have a monitoring system built into your medical billing process that identifies:

1. To which insurance companies does your state’s clean claim law apply (some payers are exempt);

2. The date your practice initially submits each medical claim;

3. Any events that legitimately give the payer more time to process the claim (for instance, a request for additional information);

4. Events that restart the clean claim clock (e.g., your office replies to a payer’s information request), and

5. The date from the payer’s communication about the final disposition of the claim.

The design and implementation of the system and reporting can be challenging, but it can pay huge dividends in terms of the penalties from payers and in the way in which you will make payers take notice of your claims next time. You may actually find, as have other aggressive users of the clean claim law, that you will receive calls from payers assuring you they will process your claims quickly and asking you to please stop submitting complaints.

One way to quickly get started using the clean claim law is to run a trial on a payer that you feel consistently takes more than 30 days to ajudicates claims. Find a small number of large claims for this payer that have gone past 30 days and then conduct a trial run with those claims. This will allow you to learn the fundamentals of how to submit and monitor complaints and see the results of your complaints.

Copyright 2006 by Carl Mays II