10 strategies to promote clean claims in your medical practice
Clean claims. It’s what every medical practice strives to provide. What is a clean claim? When a claim is ‘clean,’ it means it doesn’t include any errors. It transmits from the electronic health record (EHR) to the clearinghouse and then the payer without any issues. The patient’s coverage is active on the date of service, medical codes support medically necessary services, demographic and other information on the claim is accurate and in the correct fields, and the claim is filed within the payer’s timely filing window. Here’s the CMS definition of a clean claim: “One that does not contain a defect requiring the Medicare contractor to investigate or develop prior to adjudication.” Medicare and commercial insurance companies pay clean claims without question, which means revenue keeps flowing into your medical practice.
What’s the alternative? Delayed or denied payments for not following the rules. Fortunately, medical practices can learn the definition of a clean claim and then take steps to promote clean claims processing.
Here are 10 of those steps:
1. Know your clean claim rate. If you don’t know there’s a problem, you certainly can’t fix it. To determine what percentage of your claims yield payment on the first try, divide the number of claims that pass all edits without manual intervention by the total number of claims accepted into the claim processing system for billing. An acceptable rate for clean claims processing is at least 80%, though ideally it would be 90% or higher.
2. Update patient information regularly. This includes demographic and insurance information. You can do this in advance before the patient presents for their appointment, or you can ask patients to arrive 15 minutes early. Another option is to leverage technology (e.g., a check-in kiosk or online patient portal) so patients can update their information themselves. The goal with each of these approaches? To spend a few extra minutes getting it right and satisfy clean claim requirements.
3. Perform real-time eligibility checks. If the patient’s health insurance isn’t active on the date of service, or it doesn’t cover the services they need, you’re going to have a problem getting paid. It’s better to know about coverage-related issues in advance so there aren’t any surprises.
4. Ensure any necessary prior authorizations are in place. This can sometimes be a time-consuming step, but obtaining prior authorizations is well worth it in terms of promoting a clean claim and meeting one of the most important clean claim requirements.
5. Keep track of timely filing limits. There’s nothing more frustrating than a timely filing denial. That’s because it means you missed the deadline. All other information on the claim might be accurate, but when that window of time for claim submission closes, it’s ‘game over,’ and you’ll definitely get a denial. Every payer might be a little different in terms of how long after the date of service you have to submit the claim, which is why it’s important to track this information and keep it on your radar.
6. Focus on documentation and coding specificity. You’ll need accurate and specific diagnosis and procedure codes as well as the clinical documentation to justify reporting them. A nonspecific code can deny or delay payment. The same is true for invalid codes. Staying up to date new, revised, and deleted codes is an important step in meeting commercial payer and Medicare clean claim requirements.
7. Monitor payer bulletins and announcements. Commercial payer and Medicare clean claim requirements change frequently, and if someone in the medical practice doesn’t monitor this information, it becomes easy to fall into certain traps that can cause billing snags. Sign up for payer email lists, and bookmark payer websites so you can visit them regularly.
8. Leverage claim scrubbing. Your practice management system should include built-in claim scrubbing that detects and eliminates billing code errors and reminds you to append any necessary CPT modifiers. The result? Fewer denied or rejected claims.
9. Review denials. If you don’t review denials, you’ll have no sense of the breadth and scope of your problem. Taking a proactive approach can help you improve your clean claims processing and mitigate risk.
10. Make time for staff education. Healthcare is a dynamic industry, and everyone in the medical practice plays an important role in promoting clean claims. Role-specific education is critical.
Conclusion
Clean claims processing helps medical practices in many ways: It promotes healthy cashflow, reduces costly rework, and mitigates the risk of being flagged for potential fraud and abuse. Working with the right EHR and practice management vendor can make a big different. Learn how edgeMED can help and be sure to check the Healthy Snacks blog for more expert insights, best practices and industry trends.
