Clean Claims

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What is a clean claim? 

A clean claim is a claim that was accurately processed and paid the first time it was submitted to the insurance payer; it is the ultimate goal in medical billing.

Why do you want clean claims?

When a claim is rejected, it delays your payment, inflates your accounts receivable, and increase your operational costs because the whole claim cycle must begin again.  Your staff or billing company will have to identify/review the denials and perform any necessary corrections, in order to resubmit these claims to the payers.  Thus, it is in your best interest to ensure that you have a high percentage of clean claims.

Things that prevent you from having clean claims

Here are some factors that prevent you from having clean claims.

  • Incorrect patient demographical information.
    • Some examples are (1) incorrect patient name, (2) incorrect policy holder’s name, incorrect insurance (4) incorrect policy number; (5) incorrect date of birth
  • Patient eligibility was not checked.
    • It is vital that patient eligibility and benefits be checked prior to the patient’s appointment. Membership verification, coverage status, and other pertinent information, such as deductible, coinsurance, and copays amounts should be obtained.
  • Prior authorization was not obtained.
    • Some services require that an authorization be obtained from the insurance prior to services being rendered. A pre-authorization requirement designates that the insurance company is requiring the provider to get permission to provide the service.  This process ensures that the patient has sufficient benefit funds for the service or if the service is even eligible for payment under the patient’s policy.
  • Incorrect/improper codes (CPT and ICD) were submitted.
    • It is important to know the coding rules of the insurance carriers. Your clearinghouse should also give you the ability to scrub your claims by using its rules engine.
  • Incorrect/improper modifiers were submitted
    • It is also essential that you know how your insurance carriers want you to submit modifiers (e.g. submitting modifier 50 or right side and left side modifiers). This is also where you might come under scrutiny.  Always remember that CPT codes and modifiers should be submitted based upon supporting documentation; they should never be falsified in the hopes of getting a procedure paid.
  • Quality checks were not performed on claims prior to their submissions to the insurance carriers.
    • Billing staff should perform quality control before submitting the claims. Demographics, CPT codes, ICD-10 codes, and modifiers should be checked before the release of claims.
  • Requested medical documentation were not sent to the insurance carrier.
    • Procedure documentation like chart notes and reports should be sent to the insurance carriers if they require or request more information.


Our Recommendations

Always scrub your claims before submission.  Claims should be reviewed and corrected if necessary before they are billed out.  It is essential that your billing staff stays current with all the policy changes by the insurance carriers.  Additionally, it is incumbent upon providers to have internal policies and procedures that support a continuous learning model so that the effectiveness and efficiency of the revenue cycle can continually improve.  Documented procedures of the claim correction process should be in place.  You should utilize reporting and analytics to identify critical issues with insurance payers that are affecting your A/R days.  Then work with the payers to get the issues resolved.  Keep track of payer issues to utilize in your contract negotiations.  Create a culture of accountability for your staff so that targets and goals can be met.  While some of the denials are out of your control, some are preventable.  The preventable ones should be examined, resulting in a permanent fix for these denials.

Physician Revenue Navigators is a premier company that provides revenue management for healthcare entities.   Contact us to learn more about how we can help you collect more revenue.

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