"Eye On Managed Care: Getting Reimbursed -- On Time"


"Eye On Managed Care: Getting Reimbursed -- On Time"

It all starts with a "clean" claim (whatever "clean" means).

by Gil Weber, MBA
Consulting Editor

Adapted with permission from Optometric Management
© Copyright, 2001. All rights reserved.
February 2001

On the best day of the year, managed care is an administrative hassle for your staff. It's especially difficult and frustrating when your staff tries to do the right thing but then runs into a brick wall collecting for services rendered.

Perhaps nothing in managed care is as frustrating or irritating as when the staff confirms eligibility (and/or obtains prior authorization), you provide services, staff submits a claim(s), and then a few weeks later you receive a letter denying or delaying payment. The reason? According to the insurance company the claim had problems; it wasn't "clean."

For years, I've written and lectured about prompt payment laws and the many holes contained in them. One sub-topic I first addressed 3 or 4 years ago was "clean" claims and how easy it is for a payer to manipulate the definition of clean to its own advantage -- and to your disadvantage.

It's clear as mud

Though most states now have some sort of prompt payment law (claims settlement act) or regulation on the books, that fact alone hasn't made life easier for many practitioners. Eyecare professionals across the nation continue to have problems collecting on monies owed by some HMOs, vision plans, and other third-party payers. The problem centers on a simple fact -- "clean" is often defined by the one who's paying the claim.

This means that with each HMO or vision plan setting its own rules, your staff must jump through a different set of hoops each time it files claims. Even if your practice files electronically, the process can be problematic.

The golden rule: He who has the gold, rules

Typically, payers can impose upon providers almost any requirements they wish when it comes to the information necessary for processing and paying a claim.

The ability to self-define also allows payers to reject claims for seemingly inconsequential omissions -- things so minor that they shouldn't prevent timely processing.

(Some would say that claims are rejected for no other reason than a desire by certain payers to keep the money in their accounts as long as possible).

According to an article in the December 4, 2000, issue of AMNews, a daily online update from the American Medical Association, The Health Insurance Association of America reports that a quarter of all claims are rejected because they are not clean. And MedUnite, an electronic claims-processing joint venture by seven large health plans, including Aetna, Anthem and Cigna, claims that 50% of claims contain mistakes.

While claims can be sent back for other reasons, such as uncovered services, nearly 80% of delayed payments at United Healthcare lack 'one of the basic pieces of data' on the billing form . . . .

So, what can you do?

Check to see that "clean" is defined in each of your provider agreements or in documents Incorporated by Reference. If they're Incorporated by Reference, insist that you're provided with copies of those documents.

(Note: Incorporated by Reference essentially means terms and conditions included by implication and legally binding, even if not physically attached to the provider agreement or made available for your review. So, it's essential that you have any such document in your hands to know what it specifies.)

Without a clear and unambiguous definition of "clean," your staff can't know whether they're providing every required piece of information to assure accurate and timely payment.

If "clean" isn't clearly and unambiguously defined, then it's essential that your provider agreements be changed either at the next anniversary date or (preferably) immediately amended.

An experienced managed care attorney can provide the necessary verbiage or can review the payer's agreement. And don't hesitate to ask for the specifics from each plan even if your state is among those that already define "clean."

Create a claims-submission matrix for your staff. The matrix should contain the specifics for each plan and will then allow those filing claims to verify that all required information is included or attached.

(Review your claims processing software because you might be able to tweak it to flag any empty or incomplete fields.)

It's up to you

Prompt payment laws can and should help, but realistically it's up to you to take the initiatives that will allow the laws to work as they're intended.

You'll need to plug the loopholes, and you'll need to make it as difficult as possible for payers to play games with your claims.

States That Do, States That Don't

Despite the good intentions of legislators and regulators, only 12 states define "clean" in their prompt-payment laws. Sadly, according to the American Medical Association's (AMA) Private Sector Advocacy unit, most of those laws are inadequate.

The 12 states that have, to one extent or another, defined what they determine to be a "clean" claim are: Arizona, Colorado, Florida, Kansas, Kentucky, Minnesota, New Mexico, Pennsylvania, Tennessee, Texas, Virginia and West Virginia.

However, 27 other states with prompt-payment laws or regulations don't define "clean." They include Alabama, Arkansas, California, Connecticut, Delaware, Georgia, Hawaii, Illinois, Louisiana, Maine, Maryland, Massachusetts, Michigan, Mississippi, Missouri, Montana, Nevada, New Jersey, New York, North Carolina, Ohio, Oklahoma, Utah, Vermont, West Virginia, Wisconsin and Wyoming. (Source: AMA)

Gil Weber is an author, lecturer and practice management consultant to the managed care and ophthalmic industries. He has served as Managed Care Director for the American Academy of Ophthalmology.

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