Advocacy for own claims

Are health insurance providers specific to your claims?

Federal regulations require that 90% of “clean claims” be paid to health care providers within 30 days. But what if the payer doesn’t pay within 30 days? What if your claims are impure?

The problem is – who determines what a clean claim is? Your payer? Your MAC (Medicare Administrative Contractor)? If you charge 100 claims and get paid for 50, because 50 are denied as not “clean,” how do you know if the ones that were denied were actually unclean?

Then, if you disagree with the decision of the person who says your claims are not honest, where can you appeal that decision? Can you appeal? The answer is often no. In a glaring case, you could take legal action and argue that the MAC (or whoever it is) isn’t doing its job properly.

Medicare and Medicaid billing, reimbursement, and appeal processes are crystal clear — and sometimes run counter to American values ​​and concepts, such as due process and property rights.

The Centers for Medicare & Medicaid Services (CMS) codified the aforementioned rule – “90% of clean claims must be paid to the provider within 30 days”, but never codified an appeals process to challenge decisions. A clean complaint is defined as a complaint that can be handled without obtaining additional information from the service provider or a third party. It includes a claim with errors from the state claims system. This does not include a provider claim that is being investigated for fraud or abuse, or a claim under review for medical necessity.

“Clean” doesn’t mean perfect, because the Social Security Act states that applications don’t have to be 100% perfect to be “clean.” There is no rule or law that requires statements to be perfect. CMS’s inability to create a definition of “clean” or an appeal process for the determination puts vendors in a very uncomfortable position: their reimbursements are based on another entity’s subjective decision as to whether they have charged “clean” claims, and there is no way to refute such claims or defend against what may be erroneous determinations.

In CMS Manual System, Pub. 100-04, Medicare Claims Processing, dated July 20, 2007, CMS uses the term “other than clean” to describe an unclean claim. CMS also stipulates that “other than clean” complaints must be brought to the supplier’s attention within 45 days. As in, you should be notified of your alleged uncleanliness within 45 days.

In Southern Rehabilitation Group, PLLC. c. Burwell, 683 Fed. Approx. 354 (6and Cir., 2017), an inpatient rehabilitation healthcare service provider filed a lawsuit against HHS, alleging fraud and other wrongful conduct, such as failure to pay in a timely manner (within 30 days ), when processing Medicare claims. HHS argued that the unpaid claims were not “clean.” The Court ruled that the “net claims” provision of the Medicare Act referring to treatment that “prevents timely payment” refers to treatment that delays it. The court allowed HHS to classify the claims as “unclean” and the provider had no recourse.

It just seems that so many determinations in Medicare/Medicaid are subjective:

  • “Credible” allegations of fraud (to see Blog);
  • “Clean” claims;
  • The memos are “compliant”;
  • The patient must not have been designated as an “inpatient”;
  • 75% “compliant” for three consecutive months (to see Blog); and
  • Managed care organizations terminating your contract (to see Blog).

Many decisions that negatively affect providers have no mechanism by which they can disagree, push back, or appeal.

Note on programming: Listen to live RAC reports from Knicole Emanuel every Monday on Monitor Mondays at 10 Eastern.

About John Tuttle

Check Also

10 Keys to a Successful Pharmacy Audit Call | CP Oberheiden

Medicare, Medicaid, and Pharmacy Benefit Manager (PBM) audits can result in substantial losses for pharmacies. …