Clean Claim in Medical Billing: Understanding Your Clean Claim Rate

58% of insured adults report some issue with their health coverage.

This includes some common roadblocks like:

• Claim denials.
• Pre-authorization issues.
• Provider network problems.

Without a smooth billing process, healthcare providers struggle to keep doors open for their patients. Unfortunately, medical billing teams encounter different kinds of issues everyday. The most common: problems with claims.

Having a high clean claim rate helps to ensure a seamless administrative workflow. Today we will focus on what a clean claim is, how they help your revenue cycle, and more. Let’s get into it!

What is a Clean Claim in Medical Billing?

A clean claim is one that accurately reflects information and documentation. These are then more easily processed by health insurance companies without delay. The higher your claim accuracy, the faster your facility receives reimbursement. Clean medical claims help you maintain an efficient revenue cycle.

On the other hand, a dirty claim contains errors and incomplete documentation. These claims are defective and lead to delays or denials in payment. While a clean claim meets all payer requirements, dirty claims are full of errors. Let’s look at the specific characteristics of each.

What are the Characteristics of a Clean Claim?

• Information is complete and accurate.
• Documentation requirements included.
• Correct medical coding.
• Meets submission guidelines.

What are the Characteristics of a Dirty Claim?

• Information is incorrect or incomplete.
• Missing documentation.
• Medical coding errors.
• Does not meet payer requirements.
• Submission is outside of the allowed timeframe.

Why is the Clean Claim Rate Important in Revenue Cycle Management?

A high clean claim rate indicates that your claim submission process is accurate and efficient. In other words, your business is collecting on accou with little problem. Having a smooth medical billing operation optimizes your entire billing workflow.

To find your clean claim rate, calculate by dividing the number of claims that pass all edits by the total number of claims submitted. Then multiply by 100 to get a percentage. Let’s look at the importance of clean claims and the consequences of not maintaining them.

Importance of High Clean Claim Rates in Healthcare Organizations

In healthcare revenue cycle management, a higher clean claim rate can mean:

• Reduced claim rejections.
• Improvement on cash flow.
• Ensured compliance.
• Reduced employee burnout.
• Minimized errors.

Consequences of Low Clean Claim Rates

On the other hand, having a low clean claim rate can negatively affect your entire billing cycle. Your revenue cycle might suffer if you leave dirty claims unchecked.

You can expect:

• Time wasted correcting already submitted claims.
• Lost revenue due to rejected claims going unfixed.
• Delayed reimbursements on services.
• If errors are too frequent or serious, you may also see a payer deny the entire claim.

How to Improve Your Clean Claim Rate

If you are having issues with your claim rates, don’t worry! You are not alone.

To improve your clean claim rate, there are some items to focus on first. Make sure your front desk staff is gathering the correct information from patients. Even a misspelled name can result in a claim denial.

Here are a few more suggestions when it comes to raising that clean claim rate:

• Utilize real-time eligibility checks.
• Instill accurate coding and billing practices in staff.
• Frequent training for the billing team.
• Invest in medical billing software.

Prevention is the best medicine in healthcare, and that goes for medical billing as well! With this mindset, you can make sure your claims are clean the first time going through.

Implementing Efficient Claim Scrubbing Techniques

Revenue cycle management (RCM) software is another key tool to consider. This technology offers modern medical billing services such as claim scrub features. Claim scrubbing is the process of double checking your claims before sending them to the payer.

Through a third-party clearinghouse, you can have your claim thoroughly reviewed for errors. Saving you time by immediately alerting you if there is information missing. By scrubbing your claims before submitting, you increase the number of claims that pass initially. Therefore, reducing claim rejections.

Common Reasons for Claim Rejections and Denials

If you do struggle with regular claim errors, it might be time to pause and figure out why. For example, claims that involve durable medical supplies often face denials. This is usually due to missing prior authorization or failure to document medical necessity.

There are many different reasons that prevent the claims from completing their cycle.

This can stem from any of the following:

• Inaccurate patient demographic information.
• Insurance coverage lapses.
• Incorrect usage of medical codes.
• Pre-authorization issues.
• Diagnosis codes not matching the services provided.
• Lack of medical documentation.
• Out-of-network billing.

Mind you this is not the full list, but some of the more common issues your billing and coding team may face. In reality, there can be many reasons that prevent the claim from being clean.

Here are some tips on handling rejections and how to improve clean claims rates:

• Review the denial codes.
• Correct errors immediately.
• Prevent repeat errors by establishing workflows.
• Monitor any denial trends as time goes by.

What are the Best Practices for Submitting Clean Claims?

When it comes to improving the clean claim rate of your medical practice, your team must familiarize themselves with best practices.

To raise the total number of claims accepted on the first try, consider outsource medical billing services to help you submit the claim. Otherwise known as a healthcare revenue cycle management company.

Working with Healthcare Revenue Cycle Management Companies

When you work with a reputable revenue cycle management company, you can be sure your claims will meet compliance and payer standards.

Through this investment you will receive:

• Trained staff that are up-to-date with all medical billing reforms.
• Access to tools such as claims scrubbing.
• A higher percentage of claims accepted upon first submission.
• Higher performance metrics between different types of claims.
• Access to helpful information like the receipt of the claim after submission.

Improve Clean Claims as a Healthcare Provider

A solid claim processing procedure is the single most important determinant for cash flow for healthcare providers. The ability to file a clean claim right the first time is the difference between steady cash flow and constant payment delays. Avoid having to resubmit the same claim over and over by incorporating an RCM solution into your operations.

Ensuring your services listed on the claim are properly coded, complete, and have the correct documentation can be a tedious process. That’s why having a clearinghouse do it for you is a great way to significantly improve your claims result while also reducing administrative burden on your team.

Submitting accurate claims that can pass payer edits without issue should be your business’s number one priority. This way you can benefit from faster payments, fewer denials, and a stronger financial baseline.