The law’s main premise is that a payer must reply to a valid claim within a certain amount of time (usually around 30 days for electronic claims).

In order to efficiently use the clean claim rule, your medical billing process must have a tracking system that flags:

• Which insurance firms are covered by your state’s clean claim statute (some are exempt)?
• The date on which your clinic submits each medical claim for the first time;
• Events that bring the clean claim clock to a halt (e.g., an information request from the payer),
• When your practice has responded to payer requests by taking action;
• The date on which you received the final adjudication decision from the payer.

The prospect of carefully tracking all of this data may seem intimidating, but with the right system architecture, it is both achievable and desirable. Your claims will pay faster after you file a few Clean Claim law violation reports. I’ve witnessed cases when payers have contacted solely to reassure the practitioner that claims will be processed swiftly.

Running a trial on a payer that frequently takes more than 30 days to adjudicate claims is one method to quickly get started using the clean claim law. Find a small number of significant claims for this payer that have been open for more than 30 days and run a test with them. This will enable you to understand the foundations of how to file, monitor, and view the results of complaints.

Tips for Getting Your Medical Practice to Have a 95% Clean Claims Rate

How can your medical practice attain a clean claims rate of 95%? Despite the fact that this may appear to be a tall goal, there are several medical billing tactics your medical practice may apply to help increase your clean claims rate – and your entire revenue cycle management!

Keep patient records up to date.

There’s a lot of patient information that can change—and change quickly—from contact information to insurance carriers and more. Patients must check or update their current information before getting treatment, as faulty patient data is a leading source of denied claims. To reduce delays, use exact documentation to help check patient information ahead of time, and have patients update their paperwork at every visit (or even sooner with automated reminders).

Prior to the date of service, double-check your eligibility.

Patients that come to your office on a regular basis are known as established patients. They’re also the patients who your employees might presume haven’t had any recent insurance changes. Most denied claims, however, are generally the result of outdated established patient insurance information. Collecting and confirming every patient’s primary, secondary, and even tertiary insurance at least five days before their scheduled service is one step toward a 95 percent clean claims rate.

It’s also vital to double-check any in- or out-of-network benefits, copays, or deductibles.

Keep in mind the deadlines for filing insurance claims.

In most cases, filing a claim necessitates submitting it within a specific time frame. Any claim submitted outside of the window will result in a higher number of refused claims.

 If you want your practice to have a near-perfect clean claim ratio, one of the best ways to do so is to pay attention to claim deadlines and handle any concerns with patient coverage prior to their date of service so the claim is not submitted late. Aim for authorization between three and five days prior to service as a best practice.

Even the cleanest, most well-documented claim can often take weeks, if not months, to process. In the meantime, the practice loses out on revenue. This is why many of them opt to have their billing handled by a third party. Ultimately, WWS contributes to a smooth, continuous flow of revenue that benefits the bottom line of health practices. Contact WWS today to learn more.

Revenue cycle management is the process that manages claims processing, payment and revenue generation, and often entails the use of technology to keep track of the claims process at every check point. 

Effective revenue cycle management will maximize the return on investment of a hospital. If you don’t have a good system in place, it can be challenging to juggle the various overhead expenses while still needing to pay the physicians and other members of staff. In addition to that, hospitals who want to stay modern and competitive, need to be willing to invest in newer technologies. Since effective RCM should leave to higher ROI at an organization.

Here are some areas were hospitals should always be looking to improve.

The Significance Of RCM

• Effective RCM speeds up the collections process and ensures that claims are being collected. Not only does it promote faster inflows, but it also handles denied claims.
• Many hospitals are still missing out on revenue opportunities because they fail to follow up with denied claims. In addition to all that, RCM deals with coding claims, collecting copays, and patient insurance eligibility.
• Not only does this drive up costs for an organization (needed to pay for postage and printing), but it also is time-consuming and not necessary.
• However, by utilizing new information technologies, you can speed up the processing of claims by not having to worry about manual processes.
• Hospitals nowadays should be looking to cut down on facets such as unnecessary paperwork and verifying contracts with every payer.

Simplify Your Processes

RCM has a lot of moving components.

For your billing and collections processes to be successful, there needs to be synergy within your hospital. Everyone needs to have defined roles within the organization; however, that does not mean there should not be cross-training to some degree.

A hospital is composed of physicians, nurses, administrative people, billing staff, and many others. It is essential that your hospital staff shares common goals and recognizes that they are a team and are in it together. In many cases, when the RCM of a hospital is lagging, it can be attributed back to misunderstandings of responsibilities, inadequate amounts of training, and when people not being on the same page.

Schedule a free live demo to learn more about RCM. Our team will assists you to give your operation the revenue cycle solutions it need!!