Your practice’s ‘clean claim’ ratio is the average number of claims paid on first submission. How’s yours?
Every provider would love to reach a percentage above 95%, but it’s not really the number that matters. Practice budgets are tight, and your staff’s time is the most precious resource you have.
So if your clean claims rate is less than 85% (or worse), it means your staff is likely spending lots of time on identifying denial reasons, coordinating with payers, and re-submitting claims.
That’s far from ideal. To make smarter use of resources around your practice, embrace these best practices that can help you get paid on first-submit more frequently.
Update Information Often
Inaccurate patient data leads to denials. But practices can’t know if their existing information is off-base when they don’t ask patients to confirm it.
How often are you prompting patients to revisit and update demographic information, policy details, and medical histories? Don’t wait for patients to tell you—make sure to ask patients to confirm forms on every visit (and send electronic or mail reminders if needed).
Focus On Timelines
Submitting accurate claims within each payer’s expected filing window is the ultimate key to soaring clean claim ratios. But you need to have a mind for timeliness before claims submittal, too.
Finding and resolving any issues with patient coverage demands concerted effort up front. Across all payers, try to verify patient eligibility at least two days prior to the date of service. For important procedures, aim for authorization within five days of the date of service.
Make Common-Sense Corrections
Are you using software to scrub claims prior to submittal? or (at the very minimum) reviewing for mis-entered fields, missing data, and other obvious mistakes?
Quality checks keep denials from occurring. Implement clear steps in your process where both technology and personnel are deployed to ensure the right details are occupying every required field, in every submitted form.
Re-check Your Modifiers
When it comes to coding, misuse of modifiers is something payers are always on the lookout for (since providers sometimes use them incorrectly in order to earn a higher reimbursement).
That shouldn’t scare you away from using them when appropriate, but it should encourage you to always give them an extra look. Have your coders flag modifiers they’re unused to using for specific payers, and communicate with colleagues to ensure proper documentation.
Monitor, Improve, Repeat
Watch your claims data for trends. Is one payer giving you extra trouble, or one staffer consistently miscoding procedures within a certain specialty? With ongoing assessment, you can identify the problems (and resolve them with training) faster.
If embracing best practices in your processes doesn’t boost clean claim submissions, explore other options. Working with a medical billing firm helps many practices reach 95% or higher reimbursement rates – allowing them to put practice resources to use in more impactful, patient-centered ways.
...and if you need help from a medical billing company...