Making the Case for Clean Claims

Medicare providers are your claims clean?

Federal regulations mandate that 90 percent of “clean claims” must be paid to healthcare providers within 30 days. But what if the payor doesn’t pay within 30 days? What if your claims are unclean?

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

Then, if you disagree with whoever’s determination it is that says your claims aren’t clean, where do you appeal that decision? Can you appeal? The answer is often no. In an egregious case, you could litigate, and argue that the MAC (or whomever) is not doing their job properly.

The Medicare and Medicaid billing, reimbursement, and appeals processes are clear as mud – and sometimes run contrary to American values and concepts, such as due process and property rights.

The Centers for Medicare & Medicaid Services (CMS) codified the aforementioned rule – “90 percent of clean claims must be paid to the provider within 30 days,” but never codified an appeal process to dispute decisions. A clean claim is defined as one that can be processed without obtaining additional information from the provider of the service or from a third party. It includes a claim with errors originating in the state’s claims system. It does not include a claim from the provider that is under investigation for fraud or abuse, or a claim under review for medical necessity.

“Clean” does not mean perfect, because the Social Security Act states that claims do not have to be 100-percent perfect to be “clean.” There is no rule or law that requires claims to be perfect. CMS’s failure to create a definition of “clean” or an appeal process for the determination places providers in a very uncomfortable position: their reimbursements are predicated on another entity’s subjective decision as to whether they billed “clean” claims, and there is no way to refute such allegations or defend themselves from what might be erroneous determinations.

In CMS Manual System, Pub. 100-04, Medicare Claims Processing, dated July 20, 2007, CMS uses the phrase “other-than-clean” to describe an unclean claim. CMS also states that “other-than-clean” claims should be brought to the provider’s attention within 45 days. As in, you should be told of your supposed uncleanliness within 45 days.

In Southern Rehabilitation Group, PLLC. v. Burwell, 683 Fed. Appx. 354 (6^th Cir., 2017), a provider of inpatient rehabilitation healthcare services brought action against HHS, alleging fraud and other wrongful conduct, such not making timely payments (within 30 days), in processing claims for reimbursement under Medicare. HHS argued that the unpaid claims were not “clean.” The Court held that the “clean claims” provision of the Medicare Act referring to treatment that “prevents timely” payment refers to treatment that delays it. The Court allowed HHS to call claims “not clean,” and the provider had no recourse.

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

• “Credible” allegations of fraud (see blog);
• “Clean” claims;
• Service notes are “compliant;”
• The patient should not have been designated as “inpatient;”
• 75 percent “compliant” for three consecutive months (see blog); and
• Managed Care Organizations terminating your contract (see blog).

Many determinations that adversely affect providers have no mechanism through which they can disagree, push back, or appeal.

Programming Note: Listen to Knicole Emanuel’s live RAC Reports every Monday on Monitor Mondays at 10 Eastern.