Clean Claims Rate

Decent Essays
Clean Claims Rate
What steps can your organization take to improve your clean claims rate?
As a nation, we are facing a unique time in the world of healthcare where value-based healthcare determines how a hospital gets paid, and value is priority, it's no longer an option for hospitals to lose potentially millions of dollars due to faulty claims denials. Therefore, submitting clean claims that do not result in denial is the most effective defense your facility has against lost revenue due to fault claims submissions. Just like preventative medicine saves money by preventing medical problems before they occur, submitting accurate billing information the first time around is a more effective way to secure revenue rather than dealing with claims
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While the measures are in place to improve communication, efficiencies and care-coordination among providers, bundled payments can also cause claims denials. This happens because the way bundled payments work is that all the services a patient receives from the physician, the specialist, the hospital, medical services, and the care provided is lumped into one fee. Therefore, any specialist that worked on the case must receive their payment from that bundled payment, and if the hospital attempts to bill for the specialist service separately, the result will be a denied claim.

2. Know the Ins and Outs of Medical Necessity

As defined by the Centers for Medicare and Medicaid Services (CMS), medically necessary is “healthcare services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”

Most healthcare plans only cover services when there has been a demonstrated need or medical necessity, established by clear, consistent and concise documentation with relevant diagnosis. However, sometimes it's not always clear whether a patient's conditions meet the established criteria for medical
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Any missing data, even the smallest human error, can lead to claim rejection. Technology is available to eliminate the manual approaches to verify eligibility and authorization, which are ridden with opportunity for simple error and require time-consuming processes of calling payers or searching their websites for the appropriate information.

The goal of a robust eligibility verification electronic system is to verify appropriate eligibility information before services are rendered, in real-time while the patient is still present in order to collect co-pays and deductibles before services are rendered. SSI Eligibility enables providers to verify accurate insurance benefits and coverage to allow for successful pre-service payment collection and accurate patient registration, in order to help reduce claims denials.

"The culture has always been, 'They'll fix it on the back-end.' Those days are gone. It's imperative we start at the time of the first patient encounter, which is pre-registration, to ensure the patient information is correct and valid. You can't be effective on the back-end without technology to ensure data quality on the front-end." - Daren Bush, director of patient financial services at Knox Community
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