For many medical practices, billing is one of the most challenging (and least fun) aspects of the business. It’s also the most critical, because without good billing practices your cash flow suffers, and your clinic won’t last long. If you have a small, independent clinic or a practice with only a few partners, your total collections may be suffering from denied or rejected claims. That is especially true if you have in-house medical coding and billing with only a small—and likely overwhelmed—team of people doing a lot of important work to submit claims.
Why Clean Claims Matter
When you submit a claim, the payer reviews it to determine whether the information is accurate and whether the services are covered. If yes on both, they pay the claim. If not, they either deny the claim or reject it. There’s a difference between the two reasons for not paying a claim (more on that later), but the end result is the same: you don’t get paid for the services you provided. Claims can go unpaid for two reasons:
Claims received and processed, but the payer won’t pay the claim. Denial could be for a wide variety of reasons, such as duplicate claims, services that are not covered by the policy, missing information, no prior authorization given, or a submission deadline passed. It requires your medical billing team to research the reason for denial so they can appeal it.
These claims are not processed by the payer because they are missing important information or don’t meet formatting or data requirements. For example, the patient’s name is misspelled or a wrong insurance policy number. You can correct the error and resubmit these for processing.
Generally, you will have a short period of time to figure out why it wasn’t paid and resubmit the claim if possible. Missing the appeals window or not succeeding with an appeal usually means writing off the amount as bad debt, for large hospital systems with huge teams and significant medical billing resources as well as small clinics.
The appeals process is frustrating, time-consuming, and unpredictable, so it’s better to submit clean claims the first time and avoid that mess altogether.
Tips to Improve Clean-Claims Submissions
There are steps your team can take at multiple points along the patient journey to reduce the chances of a claim denial or rejection.
- Confirm patient information (name, address, SSN, insurance) prior to the appointment with online check-in or kiosks/tablets so the patient can correct any errors
- Run an insurance verification right before every appointment
- Check for prior authorization requirements well in advance and get it if necessary
- Include detailed notes and documentation of diagnosis and medical necessity for treatment (EHR templates help avoid documentation errors)
- Use medical billing software that automatically fills in NPI and TIN on each claim
- Use an integrated solution that transfers information from your practice management system to your EHR, then to medical billing to avoid data entry or manual data transfer errors