Guidelines for Clean Claims Sweeping your own porch

by Shellie Pruden, DCMS director of medical practice relations

Often when I would complain, my mother would remind me to sweep my porch before peeking in someone else’s backyard. With attacks from every angle threatening the practice of medicine, those words ring true when battling insurance companies for timely claims payment.

The insurance companies are building war chests full of examples of physicians not taking time to correctly file claims. With all the hoopla about the fines and restitution orders levied by Texas Department of Insurance, physicians continue to live in the illusion that insurance companies are doing a bad job. But in looking at that “backyard,” more than 95 percent of the claims filed by physicians in Texas do not meet the clean claim standard defined by TDI. A list of required elements is available on the TDI Web site at www.tdi.state.tx.us or on the TMA Web site at www.texmed.org. The TMA developed the following list to assist its members. Failure to follow these guidelines result in an unclean claim.

Always file “Clean Claims” as defined by TDI.
• Only clean claims are protected under the law.
• Don’t assume you know the definition of a clean claim, that your claims are always clean, or that your software is compliant with clean claim rules.
• On unclean claims, carriers are required only to notify why the claim is deficient within 45 days. However, if they don’t there is no penalty.

All claims must be complete, legible, and accurate.
• Don’t include “extra information” (notes, instructions, additional markings).
• Don’t put anything in a field that doesn’t belong there, which can create “inaccurate” information.

Complete all required fields on the claim form.

Complete all conditional fields on the claim form, when applicable.

Complete all carrier-specific fields, but only when properly notified of the requirement by a specific carrier.

Include carrier-specific attachments.
• Only do so when properly notified of the requirement by a specific carrier.
• No standard attachments are required in the rule by TDI.

Have proof on file that the patient has no other coverage when marking “No” in field 11d.
• Must be updated annually and provided to insurance companies upon request.

Obtain the correct dates to put in fields 14 and 15 of the claim form.
• Never leave these fields blank.
• This helps the carrier determine pre-existing conditions.
• If multiple ICD-9 codes are on the claim, list the dates for the most primary condition/diagnosis for that encounter.
• For preventive services, default to the date of service.
• When patients can’t remember, default to the date of service.
• When unable to obtain (rare situations), default to the date of service.

When claims are audited and paid at 85 percent of the contracted rate, supply any requested information to the carrier so it can complete the audit.
• Carriers are limited to asking for only information normally obtained in a physician’s office.
• Interim payments made during the audit, yet determined to be noncovered at the completion of the audit, must be refunded to the carrier within 30 days of its request. Otherwise, the carrier can auto-recoup from any future payments.

Physicians need to ensure that their offices have the resources to meet the standard of the law. Practice management systems must be updated to include the required elements for filing clean claims.

Some additional tips from TMA Physician Services include:
1. Assign insurance follow-up staff members to particular payers, so they become familiar with those plans.
2. Don’t automatically refile claims that are denied or delayed. Follow up with a phone call first.
3. Prioritize follow-up efforts. The goal is to bring revenue into the practice, so first work the high-dollar claims and those that can be dispatched with ease.
4. Implement a process for tracking and monitoring claims.
5. Remember, staff errors can serve as a training opportunity. By identifying problem areas in staff performance, you can alter procedures and establish guidelines for better operations.

TMA will offer a practice management seminar on filing clean claims on June 11 in Dallas. For more details, contact TMA at 800-880-1300 or register online at www.texmed.org.

Continuing to submit claims that reflect the Medicare standard leaves a practice unprotected under the law and gives physicians little leverage with legislators or regulatory agencies. The benefit will be timely payment or an increase in reimbursement for the services you provided.