TIMELY PAYMENT – DEFINITION OF A CLEAN CLAIM

ASK YOURSELF:

• What date was the claim initially billed?
• Was there any written communication (request for information, denial, underpayment) from the payor? IF SO, WHEN; HOW LONG AFTER THE CLAIM WAS BILLED?
• How many days is the plan in violation of the above prompt pay statute?
• Did they underpay the claim LATE, without the required statutory interest?
• Are we contracted with the plan? IF SO, WHAT IS THE EXPECTED REIMBURSEMENT?

The staff will be tactful and professional in communicating with the payer when making this firm call and request immediate compliance to the applicable code section:

Hi, my name is ____________________, this call may be recorded for compliance purposes, I’m calling to investigate a possible violation of 42 CFR §422.520 can I give you a patient ID#?

This claim was billed on {BILL DATE} and is now {DAYS LATE} in violation of the statutory timeframes for prompt processing.  At this point, any contractual discounts have been forfeited and I have been asked to file a formal complaint with CMS for full billed charges plus interest I am calling to help {PLAN OR IPA NAME} prevent any unnecessary regulatory action by adjudicating this claim today.

Are you authorized to cut a check today to bring your plan back into compliance?

1. RESPONSES TO REBUTTALS.

A. “Under existing Federal law, a provider must submit claims within 365 days from the date of service. Upon receiving this corrected claim, you are required to reimburse this facility within (30) days from receipt of the clean claim. Prompt reimbursement of a claim is defined under 42 CFR §422.520 which states:

(a) Contract between CMS and the MA organization.

(1) The contract between CMS and the MA organization must provide that the MA organization will pay 95 percent of the “clean claims” within 30 days of receipt if they are submitted by, or on behalf of, an enrollee of an MA private fee-for-service plan or are claims for services that are not furnished under a written agreement between the organization and the provider.

(2) The MA organization must pay interest on clean claims that are not paid within 30 days in accordance with sections 1816(c)(2)(B) and 1842(c)(2)(B).

(3) All other claims from non-contracted providers must be paid or denied within 60 calendar days from the date of the request.

It is your obligation to ensure the continuous provision of quality healthcare to Medicare enrollees, and comply with the prompt payment provisions of Sec. 422.520 in order to indemnify the beneficiary enrollee for payment of any fees that are the legal obligation of the MA organization for services furnished by the provider.

I need to read you the following disclaimer: Your failure to reimburse {FACILITY NAME} is a serious matter and violates patient rights and federal regulations designed to benefit the public (UNTIMELY PAYMENT HAS A NEGATIVE EFFECT ON LEVEL OF CARE).

The provision of continuous quality health care in our region depends on {FACILITY NAME} receiving payment for medically necessary services provided to patients.

Failure to comply with this telephonic notification of non-compliance to the applicable code section may result in a request for audit, investigation and the assessment of sanction and penalties by CMS.