Improve Your Practice’s Clean Claims Rate in 4 Steps
Improve Your Practice’s Clean Claims Rate in 4 Steps
By: Mick Polo | Read Time: 7 minutes
Clean claims drive the overall revenue of health care providers and provide a healthy cash flow. Each time claims get denied, they weigh down your accounts and hold up the revenue your medical practice brings in. Denials become costly from a valuable time and financial perspective - so getting it right is important to your revenue stream, keeping your practice moving forward efficiently.
Claims payment is a key part of the healthcare revenue cycle
48% of healthcare leaders in an MGMA study identified claims payment as the biggest revenue cycle management challenge. With claims payment being a top of mind concern for many healthcare providers, and denials being another top concern, clean claims make a huge impact on healthcare providers’ success.
Keep your team focused on providing top-notch patient care by achieving clean claims the first time around. At NCDS Medical Billing, we have identified the top methods for health care providers to successfully achieve clean claims. Below, we share exactly what clean claims are and break down the premier strategies to increase your clean claims rate.
Clean Claims Defined
What are Clean Claims?
When a provider submits a claim that has no errors, defects, incomplete documentation, or unusual special circumstances, that is a clean claim. A clean claim provides all information necessary for the claim to be processed and allows for timely payments.
What is a Good Clean Claim Rate?
Healthcare providers and practices should aim for a 95% or higher clean claims ratio. If your denial rate is 5% or less, your organization is within a strong, healthy range to prosper. Generally, denial rates greater than 5% require revenue cycle improvements.
Why are Clean Claims Important?
As determined above, clean claims have ensured that organizations have covered all their bases and checked to be error-free, with all necessary and detailed documentation included.
According to a Healthcare Information and Management Systems Society survey, 76% of healthcare leaders say that claim denials constitute the greatest challenge they face. One study found that 9% of hospital charges are denied initially - and a lack of clean claims leads to these denials. Many of these claims are easily fixable, and could have been avoided. When a claim has errors or missing information, the claim is then rejected by the insurer. This is damaging to both the patient and the provider for their own financial reasons.
Top problems with the U.S. healthcare system identified by MediFind
As identified by MediFind, there are quite a few major problems within the U.S. healthcare system. Between high costs of care and inefficiencies, clean claims can help lessen the pain of problems like high costs of care and inefficiencies by helping ensure your patients’ insurance company pays as much as possible, and optimizing the medical billing process.
Past that, denials are costly. 63% of denials can be recovered when appealed. However, the cost of making an appeal is $118 on average per denied claim. These costs add up quickly!
60% of medical practices hit 2021 revenue goals
With nearly half of medical practices not hitting their revenue goals in 2021, revenue cycle improvements are needed. Achieving clean claims and reducing denials are a great place to start optimizing your revenue cycle.
Why are Claim Denials Increasing?
69% of leaders in the healthcare field shared that denials in their organizations had increased in 2021.
Over ⅔ of healthcare leaders reported that their denials increased in 2021
There are four major internal issues that often lead to increased denial rates.
- Mounting backlog of denials
- Staff turnover
- Insufficient resources
- Need for improved technology
NCDS SOLUTION: Understanding the themes of why denials are increasing is important, as it identifies what a healthcare practice should focus on to improve its clean claims rate. Our talented team of Certified Professional Coders, Certified Coding Specialists and Certified Medical Coders will fill in the blanks to support your existing workflow and provide you with feedback to educate you about the best practices for avoiding future denials, applying our enhanced business intelligence and analytics to maximize your revenue and keeping you compliant and working within the insurance guidelines and medical policies.
Review Denied Claims
Denials should not be looked at as a lost cause - instead, they’re a fantastic learning opportunity to prevent future mistakes. Past that, it’s worth staying on top of denials to see if denied claims can be turned around.
The AAPC claims calculator is a useful resource to determine how much your practice loses on denied claims and reworking denied claims. The combination of denials and reworking these denials adds up quickly. For 500 reworked claims per year at the average reworking cost of $25/claim with two physicians in practice, the cost of reworking adds up to $25000 per year.
Track and Report Denials
Make a point to track and report all the denied claims your practice receives. By quantifying the types of denials you receive and understanding when, why, and how these denials happen, there is a huge learning opportunity to improve your clean claim rate.
Identify Common Denials
For a healthcare provider, understanding where denials are coming from can help also streamline and template out the best responses to particular denials. Whether it’s incomplete medical documentation, an inaccurate insurance claim, or other errors, you can dig in on what the common reasons are for such recurring issues. By identifying common denials, which payers seem to deny for which reasons, and staying on top of what payers need, your team will increase efficiency when it comes to making claims the first time.
Catch New Denials Early
Identifying new denials early in the process increases likelihood that these denials can be turned around. Staying on top of new denials helps ensure you can still get timely payment from the payer. Being aware and attentive of denials increases your practice’s overall financial health. Contacting payers who have denied claims as soon as possible helps provide clarification about what that payer needs and reduces days in accounts receivable. This clarification can allow for your team to resubmit a clean claim. Stay informed about what payers are looking for when accepting appeals.
NCDS SOLUTION: According to the American Academy of Family Physicians, with the cost of rebilling a claim at $25 or more, the practice of reviewing denied claims needs to be efficient. NCDS uses a priority RMT (Receivables Management Task) system to identify, prioritize, track, and analyze denials to optimize the efforts of billing teams and produce the best results.
Verify Patient Information
Verifying patient information is the #1 way to achieve clean claims and prevent denials. In addition to understanding your denials, appealing denied claims, and knowing what your payers are looking for in clean claim coding, verifying that your patient information is accurate and up to date increases your clean claim rate.
Missing Info leads denial reasons according to MGMA poll
According to an MGMA poll, missing info and prior authorization are the top two reasons for denials. The top reason for denials, “Missing Info”, is avoidable through regular patient verification.
Review Patient Information
Health care providers need to validate your patients’ contact information regularly. Always have patients confirm their information is up to date, and verify their demographics. Incomplete clinical documentation is a regular cause of denials. Confirm you have all necessary medical records and provide that information as well if needed.
Determine Prior Authorization
Getting prior authorization as soon as possible helps achieve clean claims. Determine all the requirements for reimbursement up front so your practice and your patients have all the information necessary for approval.
Confirm Patient Eligibility
Verify your patients’ insurance during every visit. Ensure your practice knows what will be covered with their insurance and find the right payer the first time.
Conduct Quality Checks
Before submitting a claim, ensure all data is accurately input with all necessary fields filled in. A verification process to ensure that all information is accurate and complete will make all the difference when it comes to your revenue cycle.
NCDS SOLUTION: Tools for verifying insurance eligibility digitally and establishing a patient portal are available to you through the NCDS Client Logins. NCDS also offers outsourced Verification Of Benefits and Claim Prior Authorization services to help streamline your front office processes, save your staff time, reduce denials, and improve your clean claim rate.
Office Training and Coordination
Benefits of Clear Role Communication
Coordinating, communicating, and educating your office staff about best practices and operations to file clean claims is the key to a strong clean and accurate claims rate.
All staff members need to know what their duty is when it comes to their particular function in your practice and its operations. All roles in your practice need to be on the same page about what they need to do in their particular role to have a smooth running claims function. Each role has a key component in your practice and how they help move the claims process along.
Educate and Train Staff on Claims Submission and Common Billing Practices
Ensure your staff is trained up on your latest process requirements. Your front office staff, doctors, and back office staff all must be trained and up to date on what their role is in your operations.
Your full staff must be educated on:
- Insurances accepted in your offices
- Services provided by your practice
- Services NOT provided by your practice
Make sure staff members who work on filing medical claims and billing are up to date on efficient and proper documentation and coding practices when submitting claims.
Keep your stuff fully updated on their certifications and continue to provide training and education to your office. Communication and education are imperative to your office’s success and functionality.
NCDS Solution: Contact NCDS to set up a discovery workshop to review front and back office best practices in great detail to help your staff manage patient information and payment collections onsite, effectively and efficiently. We also offer FREE onsite and remote consultations to assess your practice's processes.
Engage an Expert Medical Billing Partner
Medical billing companies implement all of the best practices and tactics for achieving a high clean claims rate. Between preventing and mitigating denials, increasing clean claims, and knowing the world of medical billing inside and out, the right partner can keep you safe from inefficient billing practices and significantly enhance your practice’s revenue cycle.
Contact NCDS Medical Billing to talk about how we can work together to build a continuous process of clean claims submission and improve your financial performance and outcomes.
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