Tips to Succeed with Your Claim Submissions

Hi, my name is Natalie Tornese, and I’m the Director of RCM for Outsource Strategies International. I wanted to take this opportunity to go for ways to achieve success with claim submission and prevent rejections and denials.

00:16 So, What is a “Clean” Claim?

For a claim to be considered “clean,” it must be submitted to the payer within the designated timeframe and contain all of the required information in the appropriate format. Clean claims conform to the expectations and policies of the payer.

A clean claim:

• • Identifies the health professional or health facility that provided the service
  • It identifies the patient and health plan subscriber.
  • It lists the date and place of service.
  • It is a claim for covered services for an eligible individual.
  • It substantiates the medical necessity and appropriateness of the service provided.
  • If prior authorization is required for certain patient services, it would contain that information sufficient to establish that prior authorization was obtained.
  • It identifies the services rendered using a proper coding and
  • Includes additional documentation based upon services rendered as reasonably required by the health plan

Only claims that meet these requirements and are submitted in a timely manner will be paid. However, conforming to the expectations and policies of the payer is not easy given that those expectations are different for every payer. Furthermore, payer requirements are becoming exceedingly complex. This is leading to rejections, denials, claims reimbursement issues, and lost revenue.

01:44 Five Ways to Achieve Success with Claim Submission

So, let us talk about how practices can submit clean claims the first time.

Typically, when a practice creates a claim, that claim is sent to its RCM system, a clearinghouse, or a chargemaster system to ensure it is properly formatted for that plan, delivered to the right place and optimized to ensure the best reimbursement. Having the following measures in place can ensure submission of clean claims:

• First, you should check patient demographics and verify insurance eligibility: This will minimize the risk of claim rejections, it is important to review patient demographics and insurance eligibility before submitting a claim. Incorrect or missing patient information is a common reason for claim denials. Patient demographics should be regularly verified during each visit, while insurance eligibility should be confirmed before the initial visit and for all subsequent visits. Insurance coverage should also be verified if there has been a recent change or at the start of a new month or a year.
• You should perform claims scrubbing: This is a critical step to reduce rejections. The claims scrubbing process involves using a specialized software to review medical claims before they are submitted to the insurance payer. Some practice management software will have this function. Claims scrubbing software can identify and correct errors or potential issues that can cause claim rejections, denials and delays. Some of these issues are:
  • CPT codes that are inconsistent with the patient’s age or gender
  • Add-on codes that require a primary CPT code
  • Invalid or deleted CPT and Diagnosis codes
  • Diagnosis codes that don’t support medical necessity or meet requirements
  • Improper unbundling and
  • Invalid modifiers

By scrubbing claims before submission, healthcare providers can identify and fix missing or incorrect information, coding errors, and other issues, and submit clean claims. This will improve their reimbursement rates and reduce the time and resources spent on reworking denied claims.

• You should pay special attention to documentation and medical coding: Accurate coding can increase the likelihood of an approved claim. Inaccurate or incomplete codes can lead to claim rejections or denials, and loss of revenue. Accurate coding, which is an essential aspect of medical billing, can increase the likelihood of an approved claim and ensure that providers receive payment for the services they have provided. Accurate coding also helps to ensure that patients receive the appropriate level of care and that their medical records accurately reflect their health status, which can have implications for their future care.
• You should be proactive in denial management: Because, according to reports, as much as 65 percent of denied claims are just left unsubmitted, resulting in a complete loss of revenue. Healthcare providers must take action to adjust, appeal, or reopen denied claims as long as there is a valid reason to do so. To reduce the number of claim denials, healthcare organizations should first identify the root causes and then simplify the appeals process and implement effective preventive measures. They should focus on correcting common hidden causes of denials. Many patient-related rejections can be prevented with the right expertise and support to handle appeals and reduce recurring front-end rejections.
• You should improve the payer enrollment process: The most significant impact on a practice’s revenue can come from rejections related to credentialing and enrollment. Failure to understand how providers are credentialed with payers can result in improper enrollment with the clearinghouse, preventing claims from reaching payers within the required filing deadlines. Credentialing involves proving that a provider has the necessary qualifications to treat patients, including documentation of education, specializations, and additional training. After credentialing, providers must enroll in health insurance networks. Clearinghouse enrollment cannot be completed until payer credentialing and provider enrollment are finalized. Rejections related to credentialing and enrollment may occur within practice software or at the clearinghouse, and claims may even reach the payer and still be rejected. To avoid these issues, practices should review original paperwork submitted to each payer and ensure that the practice, provider, and payer information is accurately set up in their software, and clearinghouse enrollments are completed correctly the first time.

I hope this helps but always remember that documentation and a thorough knowledge of payer regulations and guidelines is critical to ensure accurate reimbursement for the procedures performed.