Clean Claims: The Gold Star of Medical Billing

Posted on

Possibly the most important task for a medical biller or coder working in the claims billing process is to send clean claims. Clean claims are error free claims that pass through payer filters without raising flags. Clean claims support a faster collection cycle, reduce denials and avoid unnecessary payer audits.

Faster Medical Billing Cycles

Many payers use automated processing systems for a majority of claims. Claims that are below utilization guidelines and free of errors route through systemic payment processing. This means payment on a clean claim can be received in less than 14 days. Faster collection time means better cash flow and reduced accounts receivable.

Avoid Denials and Payer Audits

Claims with errors result in payment denial. When a claim is denied, it takes time and resources to refile the claim or appeal the denial. Payments on many denied claims are never recovered. Even if the claim is later paid, the amount of money spent working the issue reduces the profit for the order or service.

Additionally, too many denials can result in unnecessary payer audits. Payer audits due to claim errors can take several forms, all of them bad for business. Some examples of denial related audits include:

  • Prepaid claims reviews where payers request detailed medical records prior to processing any claims;
  • Prepaid claims reviews where payers choose random claims and request records before processing for payment;
  • Postpaid claims reviews where payers ask for supporting documentation after the claims are paid and take money back if documentation is not provided.

If providers perform poorly in audits after receiving numerous denials, payers may decide to revoke the provider’s ability to submit claims. This is especially true of managed care, federal and state payers.

READ  Duties of the Registered Psychiatric Nurse

Tips for Clean Claims

Once you understand the importance of clean claims to the sustainability of a medical facility or provider, you will want to do everything you can to ensure claims are accurate. Each provider will have different processes and software to ensure quality claims. Regardless of the software or size of the provider, there are some things every medical biller and coder can do to help increase clean claim rates.

  • Check your work. Ever since second grade math teachers started telling students to look over their problems before turning in assignments, there have been people who refuse to check their work. Giving a claim the once over before sticking it in an envelope or pressing the submit button can save hundreds of lost dollars over simple mistakes.
  • Pay attention to decimal points! Check diagnosis codes, quantities and dollars to ensure you have not moved the decimal point.
  • Make sure diagnosis codes and procedure codes match, especially if the codes were provided by the system or someone else. Insurance companies will not pay for heart procedures on a claim that only shows diabetes as a diagnosis, for example.
  • Double check the insurance subscriber ID and group number. A single letter or number error can cause a claim to drop from the system. Whenever possible, compare insurance information on the claim to a copy of the insurance card.
  • Compare the patient name to the insurance card as well. No matter which spelling is actually correct, bill with the name as it appears on the insurance card.
  • Follow payer guidelines for information that must accompany claims. Common documents that are required with certain claims include letters or certificates of medical necessity, doctor’s orders or prescriptions, referrals from primary care physicians, lab results or copies of medical records.
READ  Tips for Accurate Diagnosis Coding

Providing accurate, complete claims submission is an essential skill set for any medical biller or coder. Accuracy does not only increase the cash flow for your employer. Medical billers who consistently provide accurate, efficient billing are more likely to keep their job and move up in an organization.