Introduction
A clean claim ensures substantial cash flow growth in your healthcare practice. Many healthcare facilities struggle with cash flow because of recurring mistakes in claims. Do you know how much revenue is annually lost in the U.S. due to claim denials? According to a survey conducted in 2019, $262 billion are lost each year due to claim denials. This revenue loss sometimes proves such a devastating blow to many healthcare facilities that it becomes almost impossible for them to recover. This is because of inaccurate claim submission. This loss is easily avoidable if healthcare providers specifically focus on some important areas that will be discussed in detail in this blog.
Here we bring forth incredibly effective strategies that leave ever-lasting impacts on your healthcare facilities.
What is a clean claim in Medical Billing?
A clean claim refers to a claim that is free of errors, inconsistencies, and defects. Such claims are supported by accurate documentation, less prone to denials, and easy for payers to process. These claims have fewer chances of being rejected and significantly contribute to the financial health of healthcare facilities. One of the most viable options with healthcare facilities is to outsource Medical Billing Services to a well-reputed and reliable Medical Billing company that is well-equipped and possesses high-standard infrastructure facilities to produce the most efficient results. Since claim-related concerns are about administrative processes, medical billers are in a better position to effectively handle them based on their extensive experience and advanced skills.
How Many Parties Are Involved in Medical Billing?
To achieve the desired clean claim rate, it is imperative to understand the procedure involved in it. There are three parties involved in it patient (first party), provider (second party), and payer (third party). It can distract a healthcare provider from his ultimate objective of providing the best healthcare services to his patients if he starts to provide Medical Billing services. There are multiple steps involved in the process and requires concerted efforts to improve the efficiency of a hospital and improve its revenue cycle through the best billing services.
Types Of Claims in Medical Billing
There are two types of claims in Medical Billing. Let’s delve deeper into those classifications to ensure independent and cleaning billing services for a healthcare facility.
Clean Claims
A clean claim is one that effectively fulfills all the requirements of the payer without any error, inconsistency, or defect. If the required qualities are missing and the claim has defects, inconsistencies, or errors, such bills are rejected and denied.
Here we define clean claim and its prominent qualities that a clean claim should have and that include:
- Identifying the specialty of a healthcare provider whether he belongs to a durable medical equipment provider, home healthcare provider, and the health facility he works with to establish the authority of the claim.
- Outlining the plan of the provider and the patient’s insurance policy number.
- Mentioning the place of service (POS).
- Confirming if the patient’s insurance plan covers the services rendered to him.
- Assessing if the claim qualifies as a medical necessity or not.
- Providing additional documentation as proof is required by the healthcare plan.
- Identifying the healthcare service provided through the generally accepted system of accurate service coding.
- If prior authorization is required for the service under consideration, then it is essential to prove that prior authorization was obtained before providing the service or procedure.
Dirty Claims
A dirty claim in Medical Billing refers to a claim that contains inconsistencies, errors, and defects, leading to the rejection of the claims by the Medical Billing company. Such claims require manual processing, otherwise are rejected and have counterproductive impacts on the financial health of a healthcare facility.
The following are the major defects of dirty claims:
- Details provided regarding the patient’s identity, demography, insurance plan, and provider details are incorrect.
- Details regarding the procedure performed, service provided, patient or provider’s identity and place of (POS) are either inaccurate or incomplete.
- Billing or coding for the healthcare services provided contains inconsistencies and errors, creating confusion and ambiguity.
- The claim does not fulfill the required conditions of the payer.
- Claim submitted outside the allowed timeframe.
What are the consequences of dirty claims?
It is well said that every mistake in Medical Billing has a price to pay, the same is true for incorrect claims. Here are the economic repercussions of the dirty claims.
- Financial Implications: Inaccurate claim has economic pitfalls, leading either to the reimbursement being delayed or denied which builds pressure on healthcare providers’ cash flow.
- Increased administrative Cost: If a claim is reimbursed the first time, it is the best while once it is denied, it is likely that the whole amount that the provider asks for is never paid. Additionally, it requires further resources to review, rectify, and resubmit grimy claims.
- Revenue Loss: recurrent denial and rejections of the claim not only cause denials but also negatively impact the revenue and reputation of the healthcare facility.
Healthcare facilities often prioritize deploying the best talent and resources to ensure clean claim submission which translates into accelerated revenue growth for the healthcare facilities. Utilizing an efficient claim-scrubbing process leads to improved facility revenue.
What is the industry-best approach to creating clean claims in Medical Billing?
Medical billers and coders both need to put in concerted efforts to ensure the creation of clean claims in Medical Billing. These efforts include creating accurate clinical documentation, specifying specialty practices, substantiating medical necessity, and appropriateness of the procedures performed. This information serves as a foundation for clean claim submission. Additionally, a complete and accurate medical record of the patient’s history enables precise coding for rendered services. Sadly speaking, it is the documentation of the provider’s and patients’ records that causes revenue loss to the healthcare practice.
Here, we suggest a few documentation protocols that if applied will create transformative impacts on the facility through clean Medical Billing claims.
- Inviting industry experts regularly to provide training to the refreshers for specialty physicians on proper documentation requirements.
- For effective justification of medical necessity, requires ensuring descriptions for the services billed. Medical records should also share the complete relating to presenting symptoms, tests, diagnoses, and treatments.
- Documenting start and end times for procedures billed based on duration, such as psychotherapy or infusions, is important because accurate time increments largely impact the codes used in billing.
- Prioritizing finalization and review of documentation for completion within 24 hours of patient encounters to reduce errors resulting from late additions.
- Outsource to a Medical Billing company to ensure the best results. Medical Billing companies have state-of-the-art infrastructure facilities and expert billers and coders who ensure compliant and highly efficient claim submission services.
Why Clean Claims Are Important for a Healthcare Facility
There is no denying the reality that clean claims have potentially positive impacts on healthcare facility revenue. Experts claim scrubbers make a financially positive difference in the revenue cycle of a healthcare facility. It arrests revenue leakages, accelerates revenue growth, reduces administrative costs associated with revision and resubmission, ensures faster reimbursement, and safeguards the reputation of a healthcare facility.
Software for Medical Billing
In order to further enhance the standard and efficiency of the claim submission, some medical billers approach Medical Billing software providers such as Mediusion, that can assist them in claim submission. This is one of the few best strategies to utilize technologically innovative solutions to ensure a higher clean claim rate and efficient claims scrubbing. Apart from getting fast, accurate, and transparent billing services with the use of the latest software also those services ensure compliance with HIPAA requirements. This helps ensure uninterrupted cash flow for healthcare facilities and saves a great deal of time.
Turn to Pro Medical Billing Solution for Clean Claim Submission
As per the discussion we had above, clean submission has a significant role in the financial stability of healthcare facilities. But given the overwhelming complexities involved in the process, it is somehow difficult to achieve consistent results. Strict regulatory requirements, diligence in submission timelines, specialty software choices, error prevention, and continuous training of the billing team elevate the standard of claim submission. But all this process is time-consuming, and economical, and might distract healthcare providers from focusing on creating exceptional healthcare services for their patients.
Pro Medical Billing Solution is the most convenient and viable option to outsource for clean claim submission. We have uniquely superior and industry-leading professionals with years of extensive experience in this industry. Ours is a reliable Medical Billing and we assure a 95% clean claim rate through our time-proven Medical Billing services.
FAQ
What is a clean claim?
A clean claim is a healthcare or insurance claim that is accurate, complete, and free of errors or missing information. It is submitted in the correct format, with all required codes, documentation, and patient details, ensuring smooth processing and prompt payment without delays, denials, or the need for corrections.
Explain the meaning of a clean bill of health.
In Medical Billing, a clean bill of health means a provider operates with accurate, compliant billing practices, free of fraud or errors. It ensures adherence to HIPAA, Medicare, and industry regulations for smooth claim processing. It also indicates a patient’s records show no health concerns affecting insurance claims.
What is a clean claim submission?
Clean claim submission refers to the process of accurately filing an insurance claim with all required information, correct coding, and proper documentation. This ensures the claim is processed without delays, denials, or rejections, leading to faster reimbursements for healthcare providers.
Explain the medical claim definition.
A medical claim is a formal request for payment submitted by a healthcare provider to an insurance company for services rendered to a patient. It includes details like diagnoses, procedures, costs, and patient information. The insurer reviews the claim to determine coverage, approve payment, or request corrections.
What is considered a clean claim?
A clean claim is a complete, error-free insurance claim that meets all payer requirements for processing and payment. It includes accurate patient information, correct coding, necessary documentation, and no missing or incorrect data. A clean claim is submitted on time and does not require corrections, resubmissions, or additional information for approval.
Explain Medical Definition in Medical Billing.
In Medical Billing, a medical definition refers to standardized terms and codes (ICD, CPT, HCPCS) used to classify diseases, procedures, and treatments. It ensures accuracy, compliance, and proper claim processing for insurance reimbursements.
What is the standard clean claim rate in Medical Billing?
The standard clean claim rate in Medical Billing typically falls between 90% and 95%. This means that 90-95% of submitted claims are error-free and processed without rejections or additional information requests.
A higher clean claim rate leads to faster reimbursements, fewer denials, and improved revenue cycle efficiency. Industry best practices aim for a rate above 95% to maximize claim approvals and reduce delays.
How does Pro Medical Billing Solutions ensure a high clean claims submission rate for uninterrupted cash flow?
The experts at Pro Medical Billing Solutions leverage advanced coding accuracy, real-time claim scrubbing, and compliance-driven processing to ensure an exceptional clean claim rate. Their precision-driven approach minimizes denials, accelerates reimbursements, and guarantees seamless cash flow for healthcare facilities.
