Getting Reimbursed -- on Time
By Gil Weber,
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
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
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
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)
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
(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
"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
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
- 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.
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 email@example.com.
Also, see http://www.gilweber.com.
Optometric Management, Issue: February 2001