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How to Achieve Clean Claims at First Submission

Claims July 1, 2021

What does a clean claim mean?

A clean claim is “free of any errors.” It is critical to submitting these the first time to ensure a smooth procedure. You can determine your clean claim percentage by the average rate of paid claims on the first submission. It’s best to keep this percentage high when running a lucrative surgery facility with limited resources and time constraints. So, how exactly can you secure a high percentage of clean claims while also establishing a consistent process? Here are seven steps that will help ensure clean claims submissions rate over 95%:

1) Be accurate and timely on patient information

Always ensure that patient information on claims is accurate and up to date. Patient demographic information, policy information, and medical information are all things to double-check. Detailed and up-date documentation allows your coders to give the most relevant procedure and diagnostic code(s) to support your claims. It will enable your practice to receive reimbursement for the service on time. Not only should the particular diagnosis and data about the surgery or treatment be included, but so should the patient’s medical history.

2) Verify patient eligibility as soon as possible

Providing patient eligibility verification at least two days before the DOS (Date of Service) will result in more accurate claim submission and fewer claim rejections. This eligibility verification approach also aids healthcare practices in maintaining a healthy cash flow by reducing write-offs and improving patient care. You must check all co-pays, deductibles, policy effective dates, in-network/out-of-network benefits, and other requirements during this step.

3)  Perform quality checks 

In the medical billing process, quality checks are critical in ensuring the submission of clean claims. Before submitting a claim, check it for demographic, coding, and submission issues. You need to double-check demographic inaccuracies, medical coding problems, and errors that arise throughout the submission process. Establish a system that gathers pre-authorization data on the front end and allows your billing staff to correctly measure denials for “no-authorization” so that the physician receives fast feedback. 

4) Submit prior authorization at least five days before DOS

To minimize prior authorization-related denials, submit it at least five days before the DOS. Use the best system to capture pre-authorization information on the front end accurately and allow your billing team to track “no-authorization” denials in real-time. It guarantees that the healthcare provider receives prompt input. The type of operation, which procedures require prior authorization, and whether the patient plan covers the treatment are all items that you must verify in this phase.

5) Know carrier-specific coding guidelines  

Claims may be rejected if their program doesn’t recognize a modifier. As a result, it’s essential to know what payers will and won’t cover. Using the correct modifier and adding the modifier to the correct method is among the details you should double-check.

Verify CPT and ICD compatibility, as well as the submission mechanism (paper or electronic). To ensure coding compatibility, create carrier-specific Local Coverage Determination (LCD) rules. Medical practices could also automate the claims cleaning process by developing rules engine software systems or outsourcing. You must know the answers to the following questions: 

  • What modifiers are accepted by the payers? 
  • Should you use a –50 modifier or a mixture of –RT and –LT for a bilateral procedure? 

6) Be up-to-date on new medical coding regulations

Some of the most significant difficulties affecting medical reimbursements are insurance claim denials and claim rejections. Medical coding guidelines and standards are also too complicated for healthcare providers to keep up with.

Outsourcing the claim submission process to the best medical billing firms can keep you up to date on all medical coding changes and ensure that your claims are accurately classified before submission. Claim denials are frequently the result of faulty coding or late claims filing. Claim scrubbing, in this case, swiftly detects and corrects coding problems before submission.

Healthcare practices can also leverage the automation process known as electronic claim submission to handle claims faster by installing the best medical billing software. This stage requires the verification of ICD and CPT compatibility and the kind of submission mechanism (paper-based or electronic claim filing) to ensure coding compliance.

7) Develop an effective denials management review process.

Most doctors are eager for documentation feedback, especially if their work is causing denials and hurting the practice’s bottom line. You can minimize clinical documentation difficulties by holding regular in-service events that keep physicians up to date on payer changes or new documentation needs.

Identifying all payer requirements in detail, from documentation and pre-authorization to allowable claims and proper formatting, and then applying that information to build a clean claims submission process can mean the difference between quick payments and late payments, or even non-payment some cases.

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