Clean claims: Maximizing revenue

Are you frustrated with how long it takes to get paid by insurance companies?

One of the reasons that claims can be denied and payments are delayed is the failure to submit a clean claim.

Clean claims fuel your practice’s revenue and cash flow.

Do you know what your practice’s clean-claims submission rate is?

Or do you know what a clean claim is?

Submitting clean claims is key to maximizing your ability to collect your money.

To get paid by insurers, you must submit a clean claim.

?

Clean claim definition

A clean claim is a submitted claim without any errors or other issues, including incomplete documentation that delays timely payment.

There are several required elements for a clean claim, and medical bills are denied if elements are incomplete, illegible, or inaccurate. A clean claim meets all the following requirements:

?

• Identifies the health professional, health facility, home health care provider or durable medical equipment provider who provided service sufficiently to verify, if necessary, affiliation status and includes any identifying numbers.
• Sufficiently identifies the patient and health plan subscriber.
• Lists the date and place of service.
• Is a claim for covered services for an eligible individual.
• If necessary, substantiates the medical necessity and appropriateness of the service provided.
• If prior authorization is required for certain patient services, contains information sufficient to establish that prior authorization was obtained.
• Identifies the service rendered using a generally accepted system of procedure or service coding.
• Includes additional documentation based upon services rendered as reasonably required by the health plan.

?

What is the significance of a clean claim?

Most practices have a clean-claim submission rate of 75-85% which means that 15-25% of submitted claims are not clean.

Your clean claims rate directly affects your practice’s overall revenue. Problematic billing and coding practices result in delayed or denied claims that can have devastating results for your practice.?

Every claim that is not paid on the first submittal wastes your practice’s valuable time and money.?Many rejected claims are resubmitted multiple times, often without their errors even being addressed or corrected.?In addition, when a rejected claim needs to be reworked beyond its timely filing deadline you end up not getting paid.

?

What Clean Claim Rate should do I need (want)?

In the ideal world you would have a 100% clean claim rate. But let’s be real–errors happen.

That said, you should not be satisfied with a clean claims rate under 95%, and especially anything under 90%.

Anything above a 5% claims rate is costing your business money and time. Your overall profitability depends on having your clean claims rate under control.

?

Why is submitting a clean claim is so important?

CMS and commercial insurers are required to pay clean claims within a certain time frame. If they fail to do so, they are subject to prompt pay penalties. For example, CMS must pay an electronically submitted clean claim within 24 days of being received.

?

In the ideal world you would have a 100% clean claim rate. But let’s be real–errors happen.

?

?

What has this got to do with me?

You may be thinking this is billing people issue. This is a totally myopic view.

Clean claims have everything to do with you and your office. Your office needs to check eligibility and obtain prior authorization. At check-in, your front desk needs to verify demographic information. I cannot stress how important it is to double-check spelling and numbers.

?

Submitting clean claims is key to maximizing your ability to collect your money. To get paid by insurers, you must submit a clean claim.

?

As the physician, you must have your documentation in order. You need to know what documentation is needed to substantiate medical necessity.

?

Key point:?To have clean claim, your office must collect and enter the correct information from the patient, verify eligibility and obtain prior authorization. And, if you, the provider, must provide adequate and appropriate documentation.

So how do you achieve that 95% clean claims rate?

• Keep patient information updated
• Verify eligibility prior to the date of service
• Provide detailed documentation of medical information
• Be mindful of insurance claim filing timelines
• Double-check modifiers

?

You want and deserve to be paid for the work you do. Having a 95% clean claim rate will increase your profitability by increasing your collections and decreasing the expenses incurred collecting your money. And, of course, it will shorten your revenue cycle—said another way—you’ll get your money faster.