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.
For a claim to be clean, it must meet these criteria:
"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.
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.
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.
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.
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.
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 has different timely filing limits - track them carefully!
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.
Use specific diagnosis and procedure codes
Clinical documentation must justify codes
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.
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.
Result: Fewer denied or rejected claims
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.
Healthcare is a dynamic industry, and everyone in the medical practice plays an important role in promoting clean claims. Role-specific education is critical.
Continuous education ensures everyone stays current with best practices
Faster payments mean better financial stability
Less time spent on corrections and resubmissions
Reduces fraud and abuse flagging risk
Clean claims processing helps medical practices in many ways: It promotes healthy cash flow, 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 difference.
Learn how Claims Crafter can help optimize your claims processing and be sure to check our blog for more expert insights, best practices, and industry trends.