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How to Improve Clean Claim Submission Process?


How to Improve Clean Claim Submission Process

Defining Clean Claim

When a claim is submitted without any errors or other issues including complete documentation is called a clean claim. There are several required elements for a clean claim and a submitted claim will be denied if these elements are incomplete, illegible, or inaccurate. A clean claim must meet all of the following requirements:

  • Correct information about the rendering provider, billing facility, home health care provider, or durable medical equipment provider who provided service sufficiently to verify, if necessary, affiliation status and includes any identifying numbers.
  • Correct patient/insured demographics and insurance information including patients/insured name, address (correct 6-digit zip), patient’s DOB, secondary insurance (if any)
  • Lists the date and place of service.
  • If necessary, substantiates the medical necessity and appropriateness of the service provided.
  • If prior authorization is required for certain patient services, contains information sufficient to establish that prior authorization was obtained.
  • Correct procedure codes, diagnosis codes, modifiers, units/days, rendering provider name and NPI, billing provider details with accurate TIN (linked with Payer).
  • Identifies the service rendered using a generally accepted system of procedure or service coding.
  • Includes additional documentation based upon services rendered as reasonably required by the health plan.

Submission of a clean claim is one of the crucial steps in the medical billing process. You would be surprised to know that as many as 20 percent of medical claims are denied, forcing medical institutes to spend precious resources on managing the denials or forgoing the revenue altogether. If you follow below mentioned guidelines, it will help in improving the clean claim submission process. Clean claim submission means the claim spends minimum time in accounts receivable on the payer’s side, resulting in faster payments.


Improving Clean Claim Submission Process

Find the Root Cause

Stats mention that ninety percent of denials are preventable, and two out of three are recoverable. Analyze last 90 day's claim submission data and categorize denied claims by denial codes and payers. You will be surprised to know that more than 90 percent of claims are denied due to the top 5 denial reasons. To prevent such denials, focus on these most common denial reasons. Some of the common denial reasons are:

  • Patient not eligible for service /non-covered service
  • Prior authorization not taken
  • Claim already included as part of a bundled payment of managed care program
  • Lack of demonstrated medical necessity based upon submitted diagnosis or insufficient documentation
  • Incomplete/inaccurate patient demographic and insurance information

Eliminate Data Entry Errors

Mistakes or incomplete information on the simple things like patient/ subscriber names, addresses, DOB, age, zip code, etc. which may seem relatively minor, but can cause a claim to be quickly rejected. Using eligibility reports use exact patient demographics and insurance details as per the payer’s database. Some billing software offers claim scrubbing features, which crosschecks this information against the payer’s database and highlights claims with errors. Claims marked as scrubs stay in the system and never reach the clearinghouse, so working on scrubs is important. Some billing software will proactively flag claims that have the potential to be denied, based on comparisons to a comprehensive database of similarly denied claims. If the system detects a possible wrong code, for example, it will suggest appropriate codes to prevent the claim from being denied and prevent delays in obtaining revenue. But your billing team has to review such scrubbed, flagged claims, correct them otherwise they will remain in billing software only and won’t reach the clearinghouse.

Eligibility and Benefits Verification

Almost 75 percent of denials and rejections are caused by problems with ineligibility and authorization. Depending upon the payer’s rules, even the slightest error or smallest piece of missing data may cause a claim to be rejected. You can call insurance companies and can confirm patient demographics, insurance information, patient coverage, billable procedure codes, deductibles, co-payments, and the need for prior authorization. You can create an account in the provider portal also and can cross-verify all these details easily. You have to make sure that your front desk staff must have eligibility and benefits reports for every patient visit. Billing software also provides eligibility verification with a single click, use it effectively.

Understand Medical Necessity

Whether or not a service is covered should be a relatively straightforward determination. Some health plans will cover services only if there is a demonstrated medical necessity through clear, concise, and consistent documentation with the most clinically relevant specific diagnosis. This requirement can be tricky however because it can be difficult to determine whether the conditions present in a case meet the criteria for medical necessity. To understand the medical necessity, you need medical billing experts who understand payer reimbursement policies and updated billing and coding guidelines. Talking with an insurance rep is the best way to understand the medical necessity. Whenever you are not sure, call them and understand patient coverage. While making a call ensure that you have all necessary information like provider details, patient demographics, and insurance information.

Billing for Bundled Payment Programs

Bundled payment programs are designed as a cost-savings approach to healthcare delivery, which also helps reinforce efficiencies in communication and care coordination among providers. Bundled-payment programs could be a reason for denials. For example, if a primary-care provider within a health system has billed for an episode of care that will be paid via a bundled payment, the specialist that the primary-care provider refers the patient to will be paid out of the bundle based on the original episode of care. This happens because services were covered in a bundled payment, which aggregates payments for hospitals, physicians, and other medical services into one fee. If the hospital attempts to bill for the specialist visit separately, that claim will be denied, meaning the health system will have wasted resources coding and submitting the claim that solely reflects the visit to the specialist.

To Summarize

The clean claim submission process is considered to be time-consuming which requires a team of billing and coding experts. So, the above guidelines can be utilized and modified based on the needs of your practice growth. If you don’t have sufficient time or lack an expert billing team then think of outsourcing your billing and coding operations to MedicalBillersandCoders (MBC). Outsourcing the submission of claims to the best medical billing service provider like MBC will increase your clean claim rate, reduce your overhead costs and ultimately improve your practice revenue. Clean claim submission is just one of the basic functions of our overall medical billing services, to know more about our medical billing and coding services, please contact us at info@medicalbillersandcoders.com / 888-357-3226

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