By: Harry R. Silver

CleanClaim is an essential element of any effective compliance program. CleanClaim compares your claims for the past 12 months against an extensive up-to-date data bank of billing and coding rules required by Medicare, Medicaid, private and commercial payers, and standards organizations. Your claims data moves directly from your IT system to our software vendor’s secure server. After analysis by the CleanClaim software, the results are reviewed by Potomac Law attorneys who provide you with a legal assessment and recommendations, all at a very competitive price.

Why CleanClaim?

An Essential Part of a Proactive, Effective Compliance Program.

Our CleanClaim process is an affordable and thorough solution for facilitating regulatory compliance and avoiding potential fraud claims. It is designed to make your compliance proactive and effective as required by Medicare and other payers. CleanClaim identifies potential compliance issues before they become significant problems, allowing you to take any necessary corrective action. In the event of an audit or investigation, this proactive approach to compliance allows you to demonstrate that you have an effective compliance program in place. A strong offense is always the best defense.

More Thorough and Cost-Effective Than In-House Reviews.

While you can perform your own internal audit with in-house attorneys reviewing the results, claims of attorney-client privilege for communications from in-house counsel are not always successful. In addition, any in-house audit necessarily involves employees who may decide to initiate a qui tam (whistle-blower) suit. We offer this extra layer of protection, as well as our comprehensive up-to-date library of billing and coding rules, for a low fee. There are no per-claim processing fees. You pay only for the time we spend in performing the legal analysis -- $325 per hour.

How Does it Work?

A High Quality Effective Solution Provided by Potomac Law in Conjunction with YEI Healthcare Corporation.

Potomac Law is a full service law firm that delivers high-end legal services to corporate clients. Our 45 attorneys have outstanding academic credentials and impressive professional experience, with an average of fifteen years at top national firms and/or in-house at major corporations. Our fee is only $325 per hour because Potomac Law’s modern business model eliminates the unnecessary overhead typically associated with traditional firms. This enables us to deliver high quality legal services at reduced hourly rates.

The CleanClaim analysis employs a methodology similar to that used by CMS and an increasing number of state Medicaid programs in their data mining initiatives. Potomac Law has engaged YEI Healthcare Corporation, a company with many years of experience processing claims data. YEI is used by government payers (including RACs, FIs, and other contractors), commercial payers and claims processors because of its secure server, proven ability to handle Protected Health Information (PHI) in a HIPAA-compliant manner, accurate reliable software, and exhaustive data bank of billing requirements. For each new engagement Potomac Law will enter into a HIPAA business associate agreement with YEI and will formally retain YEI to assist us in providing legal services to our client.

Simple, Easy to Use Process.

When you engage Potomac Law to review your claims history using CleanClaim, you will electronically transmit 12 months of claims to YEI’s secure server in standard claim formats, including 5010 and XML. The claims will be run through the CleanClaim library of payer requirements and industry standards to check for errors, potential issues, or any other red flags.

This library is updated daily to incorporate changes in payer requirements and rules as well as any changes issued by standards organizations. Our expert counsel will then review the results and advise you of any issues uncovered and your options for addressing those issues.

Thorough and Customizable Review.

The standard components of CleanClaim’s software’s library include:

  • Medical Necessity (Medicare MAC/FI/Carriers, Private Payers, Custom Edits)
  • Code and Modifier Validation (CPT, HCPCS, ICD-9, ICD-10, PQRI, NDC)
  • Correct Coding Usage Validation (CCI, NCCI, MUE, OCE, etc.)
  • Place of Service Editing
  • Usage Warnings, Proper Coding Guidelines (age, gender, frequency, units, etc.)
  • Reimbursement and Payment (revenue codes, DRG, MDC, APC, payment splits,
  • Claim Processing Data (CARC, RARC, status codes, etc.)
  • Fee Calculation Data

In addition to the standard components, the software can also incorporate any additional criteria you require at no additional cost.

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Marlene Laro

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