clean claim in medical billing

Clean claims are important to the revenue and cash flow of any health care business. Submitting a clean claim is vital in processing payments for medical treatments, securing approvals from insurance companies, and making sure all elements involved in the healthcare system are sufficiently and timely funded.

It is important to note that there are three parties essential to the revenue and cash flow system of medical billings and clean claim submission. These three parties are: the patients, the health care provider (biller) and the insurance company (payer). Clean claims involve documentations and processes that connect these three parties together.

What is a clean claim?

A clean claim refers to a submitted medical claim free from any error, mistake, and issues that can result in payment denials. It is composed of all documents, records, and necessary forms and details about medical procedures and treatments. These documentations are completed and submitted by the biller (health care provider) for payment processing by the insurance company (payer).

Several elements are required to create a clean claim. These elements are vital factors for timely processing of payments. All these elements must be complete, factual, and accurate with the patient’s details and healthcare needs.

What would be considered a clean claim?

So what exactly should a clean claim look like? There are comprehensive rules and discussion points that constitute the entirety of its details. However, here are the most common attributes of what a clean claim should be:

  • A clear identification of the health facility, the health professional/s involved, medical equipment and providers, and other identifying numbers
  • It should identify the patient’s information (full name, address, date of birth, etc.) and their chosen insurance plan. The plan’s coverage must also be in effect during the time the medical service was provided.
  • The claim should also identify the payer’s details, including the payer identification number, mailing address, group number, etc.
  • The healthcare provider/professional should have a valid license to perform the services, should be clean from fraudulent acts and accusations, and isn’t under investigation.
  • Every medical procedure and treatment done to the patient must be in coded format. This also includes the coded diagnosis supporting the treatments provided. All codes and modifiers should be free from errors and are not expired, deleted, or inaccurate.
  • No questions or potential issues are identified regarding the medical necessity. If necessary, it should also have detailed documentation about the appropriateness of the medical service provided.
  • If authorization was required for certain medical treatments, it should also have the necessary details.
  • It should have all documentations and records of the services provided as required by the health plan.
  • A clean claim must be finished and submitted timely, and within the given time filing window.

Clean claim vs dirty claim

Even without a medical background, one can easily tell these two apart. Clean claims are identified as claims that were accepted and paid the first time they were submitted. These are the claims that were never rejected because they were ‘clean’ and error-free.

Dirty claims, on the other hand, are claims that were filed more than once or maybe a couple times. These usually contain errors and have been denied, but can still be fixed and resubmitted for processing. Dirty claims can delay payments, trigger operation issues, and disrupt a healthcare business’ cash flow and revenue cycle.

6 Tips on how to submit a clean claim and lessen denials

Preparing and submitting a clean claim is easier said than done. Prepare yourself and be aware of the things you need to do during this process. These tips might help:

1. Keep patient details updated

Whether you’re using a system for documentation purposes, or doing this the traditional way, it’s important to keep your files and patient details updated. Automate reminders, send monthly emails to your patient database, and make sure every patient visit is being recorded. This can save from all the hassles of chasing and verifying simple information from a patient while on a tight timeline.

2. Run eligibility verifications prior to date of service

Outdated insurance information can disrupt overall processes and your cash flow. It’s important to secure information from established patients whenever they go visit your practice or your healthcare institution. Verify if all insurance details are up-to-date, especially the type of plan and coverage.

3. Detail all documentations

Proper documentation must be handled meticulously to avoid claim denials. Make sure that all procedures, treatments, medications, equipment, and diagnosis are detailed and completely accurate. Some would even secure video or audio recordings to make sure every information in the document is factual and supported by evidence.

4. Verify and double-check codings

Check and recheck medical codings to ensure that all modifiers apply to their corresponding procedures. If you still don’t have the time and proper personnel to do this, you can opt for third-party professionals who offer claims scrubbing. These codes are crucial to your claim’s approval or denial.

5. Stay on track of filing timelines

While having a clean claim requires you to keep your documentation perfect for payment approval, it also requires you to submit claims on time. An error-free claim won’t be of any use if you failed to submit it on the given filing time window. Pay attention to other factors that might cause delays, especially on issues associated with the patient. 

6. Hire a pro

Dealing with claims and preparing a clean claim in medical billing might be weighing you down at the moment. While there are other important things to take care of, clean claims are necessary to keep your cash flow and revenue from struggling. You can always choose to hire professionals, if it means lesser stress, bigger savings, and top-quality results for you.

Medical billings and its processes always need your full attention. The wonders of automation may give you an easy fix from all these, but it can only do as much. Clean claims need to be done by able hands and minds to make sure every issue, process or problem is given proper attention and necessary actions. 

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Last updated on 2022/06/21 | Posted on 2022/05/19