5 steps to achieve 95% Clean Claims Submission Ratio

Do you know how many claims your practice or center submits to carriers on a daily basis? Do you know how many claims get paid at first submission?

Every time a claim is denied by carriers, they accumulate in your accounts. These claims need revision, denials have to be identified, proper action has to be taken and the claim cycle begins again. There is considerable time and resources needed while the submission process is going all over again. Thus, it is very, very important to get a maximum number of claims paid at the first submission.

What Does it Mean to Submit a Clean Claim in Medical Billing?

A financially successful medical practice reflects submission of 'clean' claims as an important element. A clean claim in medical billing means claims, forms, and fields that are filled out clearly and accurately for processing. Clean claims have a complete and accurate documentation that doesn't delay timely payments and adhere to all legal policies.

A medical practice with a 95% clean claims rate means only 5% of claims get to payers with no mistakes with the first submittal. This means a quick and efficient reimbursement process with no time wasted on delayed payments and denied claims.

The clean claim percentage is determined by the average percentage of claims that get paid at the first submission. A profitable surgery center needs to keep this percentage high where resources are tight and time spend is crucial. So how can you make sure an optimum percentage of clean claims and build a continuous process?

Here are 7 steps that might help you achieve clean claims submissions percentage of over 95%.

1. Correct and updated patient information on claims is needed. Important information like demographics, policies, and medical details.

2. Verify patient eligibility and benefits two days before the date of service. Information that needs verification is primary, secondary, and if applicable tertiary insurances. Other information like policy effective dates, in-network/ out-of-network benefits entitlement, copays, deductibles, and services or procedure coverage.

3. Follow carrier-specific coding guidelines. Information to verify is the compatibility of CPT and ICD, the submission process can be either paper based or electronic. Create carrier specific Local Coverage Determination (LCD) guidelines to verify coding compatibility. Centers can also refer to the option of automating the claims scrubbing process by building rules engine software systems or by collaborating with other companies providing this service.

4. Authorizing procedure at least five days before the date of services. Information to verify- the type of procedure, checking with carriers if a particular scheduled procedure needs authorization in advance, and verifying if the procedure is covered under the patient plan type.

5. Mention correct modifier usage. Information to verify- application of used modifier, appending the modifier on the correct procedure. Create customized National Correct Coding Initiative (NCCI) edits guidelines to decide modifier usage.

6. Detailed medical documentation. Information to verify- need of service documentation, case history, procedure documentation, patient medication history. If carriers require, medical documents are important as supporting records for claims processing.

7. Focus on quality checks before submission. Information to verify- Check every claim for demographic, coding, submission errors before submission.

Improve Your Clean Claims Rate with 24/7 Medical Billing Services

While 100% clean claims could just be a dream for most medical practices, a 95% clean claims ratio in medical billing can be achieved with the right insurance billing practices in place. Optimizing medical billing processes with the mentioned clean claims rate tips, your practice can maximize clean claims and reduce delays and denials. Do you want to enhance your revenue cycle management and profitability in an already challenging healthcare landscape? Get in touch with 24/7 Medical Billing Services.

Ours is a team of insurance billing experts who can work with you to build a solution suitable for your practice.

Read more: How To Reduce Claim Denials From Providers?