Clean Claims: Part VI of the Back to Basics Series
Back to Basics is a series presented by your PAHCOM National Advisory Board
Charles R. Swindoll, American author and radio personality famously said, “The difference between something good and something great is attention to detail”. When we think of revenue cycles, he is absolutely correct! According to the American Institute of Compliance, most medical practices have gross collection percentages between 75% - 85% on average. But with some reorganization and increased scrutiny, we can turn that good enough percentage into something great. Working with your billing team to develop an appeals and denials policy can recoup missing money for work already done. But your billing team are not the only staff members who can assist in your endeavors to reclaim your lost income. Your front office staff are more than just the face of your business. They play an integral role in ensuring claims get paid the first time and on time.
First, let’s define what precisely is a “Clean Claim” and why it is so important. A clean claim is a claim that has no errors or omissions and can be processed without additional information. According to Rev Cycle Intelligence, a clean claim contains all the following correct information:
● Each procedure code has a supporting diagnosis code that is not expired or a deleted code.
● There are no potential issues or questions regarding medical necessity.
● The patient’s coverage was in effect on the date of service.
● The patient’s insurance covers the service provided.
● The claim submission includes all the required patient information such as full name, mailing address, and date of birth.
● The claim identifies the payer, including the correct payer identification number, group number, and mailing address.
● All required claim information is in the correct field.
● The claim is submitted within the timely filing window.
Making sure a claim is paid the very first time it is submitted is crucial to successful Revenue Cycle Management. The time and effort used to appeal denied claims can be significant, especially considering producing a clean claim the first time may only take a few small changes to your current system. To ensure that their claims are clean, most practices are using a scrubbing software that is usually Correct Coding Initiative (CCI) compliant. Unfortunately, CCI compliance may not be enough. Having the ability to include advanced edits specific to your practice is extremely important. Remember the goal is to be paid on time every time for the work your staff has already done.
Next, let’s look at the methods that can help reduce errors in the first place. We call them medical receptionists, front desk associates, administrative team, or patient access team. They have a myriad of names for one of the most important jobs in our industry, data collection. According to Novitas Solutions, a Medicare Administrative Contractor for Centers of Medicare, and Medicaid Services, some of the common reasons why they deny claims are administrative. Errors like incorrect patient demographics, transposed number/letters, no signed Advance Beneficiary Notice (ABN) and of course, no response to requests for Information (RFI) can ruin your revenue cycle and have your billing team wasting their time and energy on appeals. Ensuring that our data collection is flawless is a major component to clean claims. Make sure your front desk staff understand the importance of their jobs. They are data collection all-stars, and we could not get paid in a timely fashion without them.
Lastly, and almost as equally important as data collection is developing a strong system to address denied claims. I like the Track, Trend and Repair process. This process requires that I know the reasons why my claims were denied. I Track that information on a simple spreadsheet (although there are software systems that will do it for you). I use that spreadsheet to discern the Trend in denials. Are my claims being denied because my office has missed Request for Information filing dates? Perhaps, they are being denied because the claim was a duplicate or a crossover claim, or the insurance policy was not active for the date of service. Knowing the reasons why my claims are being denied affords me the opportunity to Repair my systems.
For example, if the RFI’s were not sent for denied claims that happened during my Biller’s vacation, I know that I need a better system of coverage for when my Biller is out of office. This is a training and coaching opportunity and a reasonably quick fix. Another more complicated example would be the Provider not in network at the time of service. In my home State, our Medicaid Managed Care Organizations sent out letters saying the longstanding regulation that requires a Primary Care Physician to be selected by the Recipient, prior to any services being rendered, was waived due to the Public Health Emergency (PHE). The theory was that by allowing Recipients to see any Physician without having to update their insurance would give them more options for care during the PHE. I kept a copy of that letter mostly because I have been in the industry long enough to know shenanigans when I see it but primarily, I knew they would deny the claims and we would have to prove we were complying with their order. We sent those denied claims back with a copy of that letter and received payment albeit late and with extra effort.
By focusing on the details of data collection, sending clean claims and tracking, trending and repairing any denied claims we can positively affect our revenue cycles. While getting it right the first time is optimal, we do not live or work in a vacuum. Life happens and sometimes things go awry. Our best course of action is to be prepared to successfully appeal denials by having strong systems in place to ensure we are living up to our contractual agreements and being paid appropriately.
