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Anatomy of a Clean Claim: Tips for Effective Medical Billing Submission

The strong anatomy of a clean claim solely depends on the careful and well-managed filing of the medical insurance claims. A clean claim must be without any discrepancies or other issues. These issues may include inadequate evidence, which can impede reimbursements. An indicator of flawless medical billing services is an increased Clean Claim Rate and the least claim resubmittals. What it implies is that the claim processes are accurate. A stronger anatomy of a clean claim serves as a cascading motion that sets up better accuracy of claims, resulting in a shorter payment time, less manual labor required, and lesser operational costs.

Strong Anatomy of a Clean Claim in Medical Billing and its Implications

The clean claims work to raise the cash flow and overall revenue of your medical practice; however, what do these imply?
Let’s define a clean claim in medical billing and how to submit clean claims so you can submit them correctly the first time.

Clean Claim in Medical Billing

A clean claim in healthcare billing is without any inconsistencies or other related factors, including insufficient documentation, which prevents payment.

Requirements of a Clean Claim

The anatomy of a clean claim depends on numerous elements; with these unaccounted for, inaccurate, or incomprehensible, the medical bills are turned down.
A clean claim must abide by the following criteria, including acknowledging the following:

  • Healthcare provider
  • Health facility
  • Residential healthcare provider, etc.

Effect of Clean Claims on Medical Practices

What effects do clean claims have on healthcare practices?
A practice’s clean claims rate comes with a direct influence on the overall revenue. Unclear or troublesome coding and billing practices lead to claim denials or even delay payments, which in turn are devastating for medical practices. Many rejected claims are refiled multiple times without addressing or rectifying errors.
So, what can your practice do to ensure cleaner claims and least claim resubmittals?

Anatomy of a Clean Claim Claims Submission

If your practice’s clean claim rate is below 95%, it essentially means that it is losing more revenue with increasing expenses owing to rejected claims. It is important to note that the first submission determines the percentage of a clean claim rate. Thus, it is vital to keep the clean claim rate higher to ensure the successful running of a healthcare practice.

5 Tips to Achieve a 95% Clean Claim Rate

Below are some tips and strategies for improving the clean claim rate and thus elevating the overall revenue cycle of your practice.

1. Continuously Updating Patient Information

Medical claims carry all important data/information regarding a patient’s visit to a facility or healthcare provider, including:

  • Personal information of the patient
  • Insurance and medical information of healthcare provider
  • Insurance company’s information

That said, this information may change from time to time. Invalid or incorrect information completely messes up the anatomy of a clean claim, thus resulting in rejections or denials.
Above are the reasons why keeping updated patient information is necessary for the health anatomy of a clean claim. It is essential to confirm and verify data/information before a patient’s visit, avoid delays in reimbursements, and ensure proper documentation. Correct and precise documentation plays an essential role in ensuring appropriate operations of medical billing.

2. Prior Authorization of Eligibility

Ideally, there are two types of patients for a healthcare provider, including:

  1. Established patients
  2. New patients

It is important to note that one of the biggest reasons for fewer clean claims or higher claim denials is old or outdated insurance information. The medical staff or the management often assumes that the insurance information of established patients hasn’t changed. Staying on top of primary, secondary, and tertiary insurance information is essential to reach the 95% clean claim rate. This information must be confirmed and verified 5 days before the patient visit/procedure. Furthermore, some other things must also be confirmed, including:

  • Prior verification of eligibility
  • Patient copayments
  • Out-of-network benefits
  • Deductibles

3. Detailed and Organized Patient Documentation

In-depth and detailed documentation is another way to ensure a higher clean claim rate. Proper patient documentation includes all details of the following:

  • Services and procedures performed
  • Patient medical history
  • Case history, in addition to any other important information needed

Proper, complete, and accurate documentation is vital to the medical billing process, as the biller has to translate the present information into codes. Incorrect or improper documentation leads to the use of wrong or inaccurate codes, resulting in imminent rejections and claim denials. Moreover, the patient information can also be periodically updated as a supplemental record.

4. Following Insurance Payer’s Timeline and Guidelines

Preparing for and submitting a medical insurance claim on time is complex, and there are specific guidelines for every payer. Such anatomy of a clean claim makes the process a rather complex one. The insurance payers’ coding guidelines may include compatibility between CPT and ICD, paper-based or electronic claims, and more. Not following the insurance-payer-specific guidelines and requirements results in rejections and claim denials.
To achieve a higher claim ratio, healthcare practices or providers must meet all requirements set forth by the payer while also keeping an eye on the claim submission deadlines. In an instance of finding a discrepancy in patient coverage, it is important to resolve the matter before submitting the claim to avoid denials.

5. Ensuring Error-Free Anatomy of a Clean Claim

The errors in healthcare coding can be human-made, including outdated, incorrect, deleted codes, or even a mix-up of alphabets or numbers. Such errors result in rejected or denied claims, bringing about a lesser clean claim rate. To ensure a high percentage of a clean claim rate, submitting error-free claims right in the first go is essential.
In addition to using correct codes, ensuring correct modifiers is also vital for ensuring an error-free claim submission. It is important to note that the modifiers are not supposed to alter the meaning of codes. The modifiers only provide additional information concerning the procedure or service performed. For this reason only, it becomes important to double-check and verify the modifier used in a claim. It is important to keep up with the official guidelines to ensure the correct use of modifiers. In addition to using a correct modifier, accurate usage of the modifier is also essential to maintain a strong anatomy of a clean claim.

Final Word

Healthcare specialists and medical practitioners are in the business of offering top-quality care to patients; however, getting paid on time and appropriately is also important to ensure the continuity and integrity of healthcare services. Accurate claim submission is a significant part of providing a solid anatomy of a clean claim when it comes to medical billing services. A robust claim submission process ensures fast turnover rates in accounts receivable, improving cash flow and elevating revenue management.

Frequently Asked Questions

Clean claims mean a claim has no defect, lacks necessary documentation, or impropriety. A clean claim must also have substantiating documentation to meet the encounter data requirements.

Some common reasons for claim rejection in medical billing include:

  • Eligibility
  • Missing or invalid payer ID
  • Missing or invalid NPI of the billing provider
  • Invalid diagnosis codes
CPT, or Current Procedural Terminology, is a medical code set in use for reporting surgical, medical, and diagnostic procedures or services. These services are further tied to entities, including health insurance companies, physicians, and accreditation organizations.



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