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What does it mean to submit a clean claim?
Generally, a clean claim has no flaw, impropriety or special condition that includes incomplete documentations and forms that causes delay on the timely payment. A health insurance provider submits a clean claim by giving the necessary data elements on the standard claim application forms, including with the attachments and required supporting documents or additional or revisions to the data elements. Specifically, a clean claim identifies the health facility, health professional, home health care provider, lists the date and place of service and any identifying numbers. More importantly, it indicates the specific service provided using generally admitted services with its details .
Failure to publish a clean claim submission has an unfavorable effect on the cash flow and revenue of the practices. It is also important to maintain a blemish-free submission in order to refrain from experiencing rejections, errors and denials that will cause delay to the claim process. The major goal of every hospital is to submit a spotless claim to its third-party services that bypass all internal billing edits and paid without the need for necessary additional intervention. This primary goal of a medical institution is to require and train its specific staff responsible for coding and billing to have an in-depth understanding of payer guidelines in order to guarantee the required compliance and preclude delay in payments. As a domino effect, delay in payments mean impact on possible maintenance charges for hospital equipments as well as professional services charges .
An obvious consequence of not submitting a clean claim would mean not getting paid at all. If the medical institution resolves to get back on track and decides to submit a clean claim, this would entail so much time to prepare and process the claim. Usually, the third-party or insurance company will require submission of explanation on why initially the hospital decides not to submit their claim. Furthermore, this may result to unearthing various documents, getting back and tracking the related patients, spending so much time making sure that there is a consistency in data. Communication between the insurance company and the hospital will be challenging. At the same time, contacting and eliciting again the necessary information from the patient will consume so much effort.
There are cases where hospital tends to appeal to the insurance company and determine to submit their claim once again; however, this may potentially result to denial of claim. Some insurance company defines a definite time for submission and claiming where partner hospitals should comply with. Failure to comply on this agreement may result to denial or processing of payments. Worst case scenario, the non-submission of a clean claim may result to legal implication as insurance company may criticize how hospitals tend to be troublesome when filing and submitting their claim. This scenario might earmark those hospitals and become known as nuisance partners. Such kind of reputation in the medical industry is a risk and not good for every hospital because it will spread among the bigger network of the hospital assembly.
Works Cited
Clean Claim and Other Information of Health Providers. (2014). Retrieved from Department of Insurance and Financial Services: http://www.michigan.gov/difs/0,5269,7-303-12902_35510-263283--,00.html
Martin, T. (2011). Revenue-cycle Management and Reimbursement: The Impact of Health Law and Health Reforms on Providers. Selected Works.
