Clean claims: two words that can make a world of difference to your healthcare practice’s bottom line.
Simply put, a clean claim in medical billing is a claim submitted by a biller to the payor with no errors, mistakes, or issues that might result in rejection or denial. Providers with a poor clean claim ratio often struggle with denials and rejections, leading to high AR and minimum collections.
In this blog, we will do a thorough analysis of clean claims, how they are made, their importance in medical billing, and the potential benefits they have on a healthcare practice. So, let’s start digging without any delay.
A clean claim in medical billing has no missing information, inaccurate documentation, or disobeyed guidelines. In simple words, a clean claim is when a healthcare provider submits a claim in its perfection that a payor can approve without any revisions or verifications. It is also used as a KPI by healthcare providers to track their billing team’s performance.
Here are some primary components that help insurers identify a clean claim in medical billing.
Clean claim rate is one of the significant KPIs often used by healthcare providers to assess their billing team’s performance. You can calculate your practice’s clean claim rate by dividing the total number of approved claims by the total number of submitted claims before multiplying the quotient by 100.
For instance, if your billing team submits 10,000 claims per month and the total number of claims approved on the first attempt is 9050, then according to the formula, your clean claim rate is 95%. Practices with a higher clean claim ratio are financially stable and have a streamlined workflow.
Is your practice struggling with maintaining or achieving a higher clean claim ratio? Our expert biller has shared some tips for improving the clean claim ratio. Let’s have an overview of them.
Accurate patient data is crucial for clean claims in medical billing. Ask your front desk receptionist to accurately record every patient’s full name, date of birth, contact information, insurance ID number, group number, and other insurance details.
It is also a very good practice to confirm eligibility verification of every patient’s insurance in real-time for reduced risk of rejections and denials.
Coding errors are among the leading causes of claim rejections and denials. Healthcare providers can improve their coding accuracy by having expert coders on their billing team. Your coders must use the latest CPT, ICD-10, and HCPCS codes to avoid payor rejections.
Also, staying up-to-date with the latest payor guidelines is very crucial for improving the claim acceptance rate. Investing in advanced coding software is also a good option to improve coding accuracy.
Incorrect provider details in a claim can lead to denial. Your billing team should verify crucial details such as National Provider Identifier, Tax Identification Number, required license numbers, rendering and referring provider information (if applicable), and other provider credentials required by the law.
You can also improve your clean claim rate by implementing a thorough review process for the claims to catch any errors before claim submission. Your billers should confirm the accuracy of key areas such as patient demographics, insurance details, codes, modifiers, and other documentation of medical services.
Moreover, you should also confirm compliance with payor-specific guidelines and HIPAA regulations. Advanced billing companies use automated claim scrubbing software for increased efficiency and better results.
A well-trained team can significantly improve your clean claim ratio and reduce denials. You should organize regular training sessions for your billing team to keep them updated on industry changes and best practices.
As a healthcare provider, you should pay special attention to your billing team’s knowledge related to the latest coding guidelines, insurance policies, payor-specific rules, claim submission protocols, and compliance with HIPAA and other regional authorities.
As accuracy is of utmost importance, automating your processes, such as eligibility checks and prior authorizations, can greatly reduce your denials. It not only reduces manual errors but also ensures compliance with insurance requirements.
Every insurance provider has different requirements for claim submission, such as filing deadlines, coding requirements, and documentation standards. Instruct your billing team to regularly review payor websites, bulletins, and industry newsletters. You can also directly communicate with payor representatives to clarify requirements.
As a healthcare provider, you should track your billing team’s performance through certain KPIs. Try to identify the patterns of certain KPIs such as clean claim rate, denial rate, rejection rate, and average reimbursement turnaround time to address recurring issues. You can use advanced billing software that offers analytics and reporting features to improve your billing processes.
You need a well-trained denial management team to increase your reimbursements. Such teams have structured processes to manage denials. However, you can also take steps to improve your denial management strategy.
Start your denial management by identifying the root cause of every denial. It could be coding errors, missing documentation, late submissions, or any other reason. Train your team to quickly resolve the problems and resubmit the updated claim within the payor’s timeframe for reimbursements. Maintaining a denial log to track common errors and develop strategies accordingly can reduce your future denials.
Understanding basic reasons for claim rejections can help you improve your clean claim rate by overcoming them. Let’s take a look at the most common reasons why a claim ever gets rejected or denied.
Submitting clean claims helps maintain the financial health of healthcare providers. They process faster, leading to quicker reimbursements with minimal denials and rejections, improving the overall revenue management cycle. Clean claims also reduce the administrative costs associated with submitting rejected and denied claims.
A higher clean claim ratio reduces the risk of audits from the payors. They help healthcare providers maintain compliance with insurance payor regulations. Accurately billed claims also increase patient trust and credibility, improving patient retention. In a nutshell, clean claims lay a foundation for a successful revenue cycle.
Most healthcare providers who manage in-house billing teams complain that it is time-consuming and complex. The regularly changing regulations and payor requirements make it even more challenging to comply with them.
To overcome these issues, most healthcare providers are outsourcing their claims to medical billing companies. Such companies have highly trained billing and coding specialists who manage the complete billing cycle for the healthcare provider. The provider has to pay a small amount in return, which is equivalent to a specific percentage of the monthly or weekly collections.
MediBilling is among the leading medical billing companies in the United States. We offer complete billing and revenue cycle management to healthcare providers. We strive to increase our partner’s reimbursements by improving the clean claim rate and tackling denied claims with efficiency.
A clean claim is one with no errors or mistakes that might result in rejection or denial. A dirty claim, on the other hand, is the one with any type of coding or billing error that might lead to rejections or denials.
Improving your clean claim rate can directly reduce your denials. To achieve that, you can either hire professional billers and manage them directly or outsource your claims to a professional billing company.
Usually, claim processing takes up to 30 days. However, clean claims that have all the required information and documentation are processed as early as 10-14 days.
Coding accuracy plays a primary role in clean claims. While there are several other factors that affect the clean claim rate, coding accuracy is where it all begins.
At Medi Billing, we provide comprehensive medical billing services that cover everything from coding and claims to payment recovery. We take the stress out of your revenue cycle across all specialties so you can dedicate your time to patient care.
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