10 Tips To Improve Clean Claim Rate

Did you know that billions of denials happen every year due to inaccuracies in claim submissions? In medical billing, healthcare providers face common challenges in achieving a first-time acceptance rate for claims due to payer policy issues, incorrect coding, or modifier use. But the question always comes to mind: how to overcome these challenges and achieve a clean claim ratio. In today’s blog, we provide 10 tips that help you improve the clean claims ratio, which reduces denials and boosts your cash flow, so you can focus more on patients without having any billing-related stress.

What is a Clean Claim in Medical Billing?

In simple words, when claims are processed without delays or resubmission, they become “clean claims”. Many healthcare professionals, whether solo practitioners or working in organizations, want to exceed the first-time acceptance rate and achieve a 98% clean claim ratio. In the medical billing process, if claims are rejected, you need to resubmit them within a specified timeframe. If they are not submitted on time, you lose revenue for the rendered services.

Clean Claim Vs Clean Claim Rate: What’s the Difference

There is a slight difference between clean claim and clean claim rate. Understand it as;

Suppose you’re a provider and your claims were processed for the first time without edits or delays, you can call it a “clean claim”.

On the other hand, calculating the percentage of paid claims by payers with the denied ones is known as the “clean claim rate”. Here’s how you can calculate it;

Number of clean claims ÷ Total amount of submitted claims * 100

For example:

A total of 100 claims are submitted, out of which only 95 are paid by insurance companies without any edits or changes to requirements. This would achieve a 95% clean claim rate.

Hence, clean claims mean an individual, error-free submission, while the score or metric measuring how many claims were processed and improved the revenue cycle is known as the clean claim rate.

Why is the Higher Clean Claim Rate Important for Healthcare Providers?

For healthcare providers, whether it’s a common physician or a specialty provider, the clean claim rate plays a critical role. It is the most essential metric of their revenue cycle, and it can have either a positive or negative impact.

Let’s discuss why the higher clean claim rate (CCR) is important for facilities and healthcare organizations in the USA.

Higher CCR, Fewer Denials

When the medical billing team achieves first-pass claim acceptance, it reduces the denial ratio, meaning no resubmissions or rework are required.

Boost Cash Flow

If the billing team achieves a higher clean claim ratio, then it means providers get paid quickly and efficiently without waiting for long, boosting cash flow.

Reduce Administrative Workload

When you submit claims on time, and they get processed the first time by insurance companies, then it automatically reduces the administrative workload because now you don’t need to find errors or resubmit claims by fixing them and investing more time. Hence, clean claims help reduce rework and save time, making the medical billing process smoother and more efficient.

Shorter A/R Days

Accounts Receivable (A/R) days track how long it takes for claims to be processed and for providers to receive payment. Hence, as long as the medical billers achieve a higher clean claim rate, it ultimately reduces A/R days, meaning you get paid within approximately 15 to 30 days instead of waiting longer.

Improve Staff Productivity

A higher clean claim ratio improves staff productivity by reducing errors and rework for submitting denied claims. Moreover, it helps them focus more on other important tasks, thereby optimizing revenue.

Better Patient Experience

When the provider is paid on time without needing to resubmit claims, they can focus more on patient care.

Best Practices to Improve Clean Claim Ratio

Whether you’re a healthcare provider who handles billing solely or a medical billing company managing the revenue cycle for physicians, you should know how you can improve the clean claim ratio. Because it helps reduce denials, speeds up the reimbursement process, and builds trust among payers.

Here are the top 10 tips to help you improve the clean claim ratio while reducing the risk of payment delays for the rendered services.

Verify Eligibility Before the Visit

In the medical billing process, the first step that billers should take is to verify the patient’s eligibility and insurance coverage. And believe us, it effectively prevents denials and helps achieve a clean claim ratio. But mostly, medical billers did it in the wrong way. They verify it when they assign codes, use modifiers, and when it’s time to submit claims – at that time, it hits if the insurance plan doesn’t cover the rendered services or the patient’s plan has expired.

The right time to check the patient’s insurance plan and eligibility criteria is even before the services are rendered. Ensure you check co-pays, deductibles, policy status, and plan requirements. Moreover, whether an insurance plan is valid or not, as eligibility errors are a major cause of claim rejections.

If your billing team takes this approach, you can achieve first-time claim acceptance, which will help you boost revenue cycle efficiency.

Ensure Patient Demographics Data

Before submitting a claim, check the patient’s demographics, including name, insurance ID, date of birth, and payer details. Often, medical billers overlook these details, and minor errors can lead to payment delays.

Prior Authorization Management

For specific services or treatments, some insurance companies or payers require prior authorization checks. It includes pre-approvals before healthcare providers deliver patient care, ensuring the claim can be processed. If the prior authorization is missing or invalid, the claim will be denied, and you will need to resubmit the claim, which will ultimately affect payments.

Pro Tip: Implement AI billing tools that notify you when prior authorization is required based on payer policies and treatments, so you never forget to submit it and get paid for the claims.

See More: How AI Is Redefining the Future of Billing Automation

Enforce Documentation Specificity (CDI)

Whether you’re handling billing for a small clinic or a large hospital, maintaining clinical documentation improvement (CDI) is necessary before claim submission. To maintain CDI, train your staff or billing team to ensure that coding, modifiers, and patients’ data are perfectly aligned with physicians’ clinical notes, which helps reduce claim rejections.

Master Modifier Usage and Auditing

When it comes to submitting claims, make sure that your billing team is a master of using modifiers and coding audits. Because it is the most critical part of healthcare billing, and a minor mistake or use of the wrong modifier can lead to claim rejections.

Keep Code Sets Updated

To achieve a 95% clean claim ratio, you should use accurate medical coding, which includes CPT, ICD-10, and HCPCS codes based on clinical notes. Therefore, always ensure you stay updated on coding changes based on payer policies and services, because using outdated or missing codes can result in payment delays for weeks or even months.

Follow Payer-Specific Rules

Across the healthcare industry, following payer-specific and HIPAA rules is essential, as failing to do so can prevent you from billing for rendered services or even result in penalties. Moreover, to meet a clean claim rate, follow payer-specific codes and rules, and ensure billing is fully HIPAA compliant so claims are processed and not denied.

Automate Claim Scrubbing

Automating claim scrubbing boosts the clean claim ratio by performing checks for prior authorization, detecting incorrect codes and modifiers, and notifying the claim submission timeframe to prevent delays.

Analyze and Categorize Denials Weekly

If denials occur, analyze their root causes, categorize them, and resolve them within the specified timeframe. So, it helps promote the clean claim ratio.

Stay Updated with Billing Changes

Across the healthcare industry, it is mandatory to stay updated on billing changes, as payer and HIPAA policies are updated each year. So, when you’re submitting claims, ensure to keep your staff updated with coding and payer-specific rules to achieve a first-time claim acceptance rate.

How eClaim Solutions Achieves 98% Clean Claim Ratio

Do you want to pass the clean claim ratio by 98%? If yes, then eClaim Solution would be the best choice for you. With over 10 years of experience in the healthcare industry, we stand out as the best RCM company for our proactive denial approach, on-time claim submission, and excellent medical coding solutions, which help us achieve a high clean claim ratio.

Whether you’re a solo practitioner or own a small clinic or an urgent care center, our expert billing team handles it effectively and smoothly. Moreover, we cover a wide range of specialties, including cardiology, nephrology, orthopedics, radiology, and much more, to help every provider receive payments on time and effectively. Contact us now for error-free claim submission and achieve a 98% clean claim submission rate!

Frequently Asked Questions

What is clean claim submission in medical billing?

Clean claim submission means your claims are processed and providers are paid without any resubmissions or rejections.

How can I pass the first-time claim acceptance rate?

By ensuring eligibility checks, managing prior-authorization approvals, using accurate medical coding, and a proactive denial approach, you can easily submit error-free claims, which helps you pass first-time acceptance.

What are the common reasons for claim denials?

There are several reasons for claim denials, but the common ones include inaccurate codes, missing or incorrect patient information, or improper modifiers, which can lead to rejections.

How can I calculate the clean claim rate?

To calculate the clean claim rate, you can simply divide the number of claims that get paid without any rejections by the total number of submitted claims and multiply it by 100. Hence, the amount you got is the percentage of your clean claims. If it’s above 95%, it’s perfect, and if it’s below, you might be losing revenue and need to develop new strategies to optimize it.

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