Steps to Achieve Clean Claims Submission Ratio

What is Clean Claims?

A clean claims has no defect, impropriety or special circumstance, including incomplete documentation that delays timely payment. A provider submits a clean claim by providing the required data elements on the standard claims forms, along with any attachments and additional elements, or revisions to data elements, attachments and additional elements, of which the provider has knowledge.

Submitting clean claims is more important than ever for physician practices. Declining fee schedules, changes due to procedure bundling and the growth of high-deductible health plans all leave groups with little margin for error when it comes to cash flow

Have you ever analyzed how many claims does your practice or center submit to carriers daily?

Do you track the percentage of claims that get paid at first submission?

Each time carriers deny your claims they accumulate in your accounts. The claims have to be revisited and denials have to be identified, appropriate action has to be taken and the claim cycle begins again. There is a substantial time and resource utilization in doing the submission process all over again.

The average percentage of claims that get paid at the first submission determines the clean claim percentage. It is ideal to keep this percentage high for running a profitable surgery center where resources are tight and time spend is crucial.

So how do you ensure optimum percentage of clean claims and build a continuous process?

Here are the seven steps that will help ensure clean claims submissions percentage over 95%:

1.  Ensure correct and updated patient information on claims.

Information to verify- patient demographic information, policy information and medical information.

2. Procedure authorization at-least five days prior to the date of service.

Information to verify- type of procedure, checking with carriers if a certain scheduled procedure requires a prior authorization and verifying if the procedure is covered under the patient plan type.

3. Verify patient eligibility and benefits at-least two days prior to the date of service.

Information to verify- primary, secondary and if applicable tertiary insurances, policy effective dates, in-network/ out-of-network benefits entitlement, services or procedure coverage, copays and deductibles.

4. Ensure correct modifier usage.

Information to verify- application of correct modifier, appending the modifier on the correct procedure. Create customized National Correct Coding Initiative (NCCI) edits guideline to determine modifier usage.

5. Undertake quality checks prior to submission.

Information to verify- Examine each claim for demographic, coding, submission errors prior to submission.

6. Follow carrier specific coding guidelines.

Information to verify- CPT and ICD compatibility, submission process- paper based or electronic. Create carrier specific Local Coverage Determination (LCD) guidelines to verify coding compatibility. Surgery center can also explore the option of automation the claims scrubbing process by building rules engine software systems or by partnering with other companies providing this service.

7. Detailed medical documentation.

Information to verify- case history, need of service documentation, procedure documentation, patient medication history. If required by carriers, medical documents act as supplemental records for claims processing.

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