Article Date: 2/1/2001

Getting Reimbursed -- on Time
By Gil Weber, M.B.A.

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 subtopic 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.


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)

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?

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.

Gil Weber is a nationally recognized author, lecturer and practice management consultant to the managed care and ophthalmic industries and has served as Managed Care Director for the American Academy of Ophthalmology. He's also on the editorial board of Optometric Management, and you can reach him at (954) 915-6771 or by e-mail at Also, see

Optometric Management, Issue: February 2001