A claims submission process aims to get your insurance company paid quickly and accurately as possible. To get paid for treating patients in need, you must submit the claim for payment as soon as possible. Patients will benefit more from your services if you ensure they receive their fair share.
What Is Clean Claim?
Clean claims submission is crucial to a successful and profitable medical practice. In medical billing, a “clean claim” refers to claims, forms, and disciplines that have been filled out precisely and efficiently. Claims that follow specific regulations and have correct and comprehensive documentation are always paid on time. The clean claim percentage is the average percentage of claims paid on the initial submission. The clean claim rate is the percentage of claims that are verified to be valid. For example, only 5% of claims are submitted to payers with no inconsistencies the first time they are submitted at a medical practice with a 95% clean claims rate. Consequently, there are no payment delays or denied claims, which means reimbursement is much faster.
Impact of Clean Claims On Healthcare Organizations
Your clean claims rate directly impacts your medical practice’s revenue. Problematic billing and coding practices in your office could result in delayed or denied claims, which would be detrimental to your practice. Your practice loses valuable money and time when claims are not reimbursed on the first submission. Furthermore, this increased the possibility of additional revenue losses if a rejected claim had to be reprocessed after the deadline. Inaccurate submitted claims may also face severe penalties. If too many claims are incorrectly filled out, your medical practice may be marked for potential fraud and abuse. False claims can cost your medical practice thousands of dollars in fines. You can protect your medical practice from financial penalties and inefficient billing by ensuring the correct billing and coding.
Tips to Ensure A Higher Clean Claims Submission Rate
Here are the following tips to ensure that your clean claims submission rate stays high:
Addressing Denials
Addressing denials in your claims submission process is vital to profitability. Claim denials cost you money and can be avoided with proper software and training. In addition, if you have an established clean claims submission process, then it’s likely that some other insurance company will cover any denied claims before they reach your company. The best way to ensure this doesn’t happen is by monitoring your coverage rate closely every quarter and looking at previous quarters’ data when deciding whether or not enough policies are being placed on file for coverage during those periods.
Latest Billing Software
The billing software that offers real-time and automated features can help you address denials before they occur. Another critical factor in keeping a high clean claim rate is to use high-quality medical billing software in your practice. Billing analytics tools are available in many programmed to assist with prior authorizations and identifying errors in codes before they are submitted. This helps the provider to create a strong revenue cycle that adheres to industry standards. Clearinghouse edits and claims scrubbing features allow you to identify and correct errors before they are submitted to the payer for reimbursement.
Updated Insurance Information
Updating payers and clearinghouses with the latest insurance information is critical. The revenue cycle can be complicated, and an accurate or updated payment record can prevent your company from losing money and opportunity. Updating payers and clearinghouses with the latest insurance information is key to ensuring clean claims submissions.
There are several ways you can update your payer records:
- Update policy numbers for each policyholder or customer that has been added over time.
- Update any outstanding balances on existing policies; or, if necessary, delete them from existing records.
Proper Coding Practices
Proper coding practices are vital in preventing denials. The best way to ensure your claims submission rate is high is by ensuring that your coders, billers and front desk employees are trained on proper coding practices. This will help them avoid denials in the first place, which means they can focus on higher-paying claims instead of denying low-value ones.
Training should also include how to address denials if they occur—for example, by informing customers about the status of their application and letting them know when it’s likely to be approved or denied based on information provided by you. If necessary, training should be conducted to incorporate new coding methods into existing procedures.
Patient Preregistration
Patient preregistration is an excellent way to avoid claim denials. Preregistration is a process where the patient’s information is collected before they arrive at the hospital. This helps to ensure that the patient’s insurance is up-to-date and accurate and that the right patient is being treated. Patient preregistration can be done in several ways, including an online system or using an app on your phone. In either case, you’ll be asked questions about what medications you’re taking, allergies or past medical history so that there are no surprises later on when entering treatment rooms or recovery areas of hospitals.
Use Automated Alerts
Automated alerts can help you identify high-dollar claims, prior authorizations and specific payers. For example, if a patient has been submitted before with a clean claim submission rate of 80%, they should be flagged as this may indicate that the patient has been submitting fraudulent claims to achieve their desired outcome. These automated alerts will allow you to quickly identify these issues and take appropriate action as soon as possible.
Keep Your Information Up-to-date
It’s essential to check your database and update it with the latest payer information. You can do this in different ways:
- You can use an automated system that will update your database whenever a change occurs. This will ensure that your data is always up-to-date and accurate.
- If you are comfortable with coding, try building your tool for updating records in bulk or by individual record type.
Monitoring The Percentage Of Your Clean Claims
A strong clean claims submissions rate is a vital part of the revenue cycle, so it’s essential to be proactive in monitoring your clean claim percentage. A good goal to aim for is 95% or higher. A robust claims submissions process is also an indicator of overall efficiency within your healthcare organization’s revenue cycle management efforts. Suppose you’re not getting enough clean claims submissions; in that case, there may be some room for improvement in other areas of your business that could help boost this number —like preregistration of patients or automated alerts sent when there are issues with insurance eligibility or prior authorization requests coming through the system (as opposed to manual intervention).
It’s also worth noting that specific steps you can take will help ensure a high clean claim submission rate: Updating payer information in your software; making sure insurance eligibility is up-to-date; preregistration with providers; automating alerts based on specific criteria like date/time submitted by the patient rather than manual intervention by staff member checking manually every single day etc.
Conclusion
Good claims processing is critical to any insurance company’s revenue cycle. If you want to be successful, you must ensure your clean claims process is strong enough to handle the most extensive claims that come through your door. Taking action before things get bad may seem appealing, but many companies have only themselves to blame when they struggle with their clean claims submission rate, which hinders their growth and profits!
