Clean Claims: Key Strategies to Maximize Reimbursements

In healthcare, the Clean Claims Submission Process in Medical Billing refers to insurance claims submitted with all the necessary and accurate information required for processing without errors. These claims comply with payer guidelines, including correct patient demographics, insurance details, procedure codes, and supporting documentation, and meet the criteria for timely submission. Clean claims minimise the likelihood of rejections or denials, ensuring smoother processing and quicker reimbursement. They are essential for maintaining financial stability in healthcare practices, as they reduce administrative burdens and are good for the financial health of your practice. 

Steps to Achieve 100% Clean Claims in Medical Billing 

Ensuring a Clean Claims Submission is crucial for a provider aiming to maintain a healthy revenue cycle. When a claim is submitted without any errors or missing information, it is called a clean claim. This helps accelerate the reimbursement and gets processed instantly by the payer. Achieving a high clean claim rate requires strategic processes, technological tools, and continuous team collaboration. 

Understanding the Importance of Clean Claims Submission 

Clean Claims Submission is essential for an efficient revenue cycle.  According to industry reports, between 15% of claims are denied, translating into billions of dollars in lost revenue annually for U.S. healthcare providers. Moreover, the Council for Affordable Quality Healthcare (CAQH) found that automating claims management could save an estimated $9.5 billion annually.

A Clean Claims Submission rate of over 90% significantly reduces claim denials, shortens accounts receivable (AR) days, and improves cash flow.

 

What are the main reasons for claim denial?

The main reason for claim rejection is incorrect details submission. Clean Claims Submission leads to improved reimbursement rates and reduced chances of claim denial.  

Incomplete or Incorrect Patient Information
Errors in patient demographics, such as misspelt names, incorrect dates of birth, or invalid insurance details, are among the leading causes of claim denials. A 2022 report by the Medical Group Management Association (MGMA) found that 23% of claim denials were attributed to inaccurate patient information.

Lack of Prior Authorization
Many insurance plans require pre-approval for specific services. The MGMA’s 2022 report indicated that 16% of denials were due to the lack of prior authorization for services.

Coding Errors
Using outdated or incorrect ICD-10, CPT, or HCPCS codes can result in claim rejections. A 2021 study published in the Journal of Medical Practice Management found that coding errors contributed to 18% of claim denials.

Medical Necessity Disputes
Claims can be denied if the payer determines that the treatment provided does not meet their criteria for medical necessity. The American Health Information Management Association (AHIMA) reported that 14% of denials were related to insufficient documentation to support medical necessity.

Duplicate Claims
Submitting the same claim multiple times can result in an automatic denial. The Council for Affordable Quality Healthcare (CAQH) estimates that duplicate claims account for approximately 8% of all denials annually.

Timely Filing Issues
Each payer has specific timeframes for submitting claims. The MGMA’s 2022 denial trends report noted that 6% of denials were due to untimely claims filing.

Coordination of Benefits (COB) Errors
Claims may be denied if there is confusion about which insurance is primary when patients have multiple coverages. A study published in the Journal of Healthcare Management found that 5% of denials were attributed to COB issues.

Provider Enrollment Problems
Providers should be enrolled with an insurance company; the claims they submit may be automatically rejected. The American Medical Association (AMA) reports that 18% of providers experience delays in credentialing, which can significantly impact claim approvals.

 

Key Statistics on Clean Claims Submission

 

Metric	Industry Average	Optimal Goal
Claim Denial Rate	5-10%	< 5%
Clean Claim Rate	70-85%	> 95%
AR Days (Accounts Receivable Days)	30-45	< 30

 

Steps to Achieve a High Clean Claim Rate:

 

Incorrect claim submissions are most likely to be rejected, so it becomes very important to take care of the requirements to reduce the chances of claim denials and rejection. 

1. Accurate Patient Data Collection 

• Capture complete and correct patient demographics, including name, address, Social Security number, and insurance details.
• Verify insurance eligibility before each visit using real-time eligibility tools.
• Double-check generational suffixes (e.g., Jr., Sr.) and middle initials to avoid mismatches.

2. Improved Technology:

• Implement claims scrubbing tools to identify and rectify errors before submission.
• Use real-time insurance discovery tools to find hidden coverage for self-pay patients.
• Automate verification processes to minimize human error.

3. Ensure Precise Coding

• Employ certified coders proficient in ICD-10, CPT, and HCPCS codes.
• Stay updated on National Correct Coding Initiative (NCCI) edits and medically unlikely edits (MUEs).
• Review claims for code combinations that should not be reported together or require specific modifiers.

4. Educate and Train Staff

• Conduct regular training sessions on payer policies and documentation standards.
• Involve clinical staff in documentation education to ensure medical necessity and proper level of service.
• Encourage collaboration between billing and clinical teams for seamless workflow.

5. Monitor and Analyze Claim Trends

• Use dashboards to track key metrics like denial reasons, AR days, and clean claim rates.
• Conduct monthly reviews to identify patterns and areas for improvement.

6. Prioritize Timely Submission

• Submit claims within payer-specific timelines to avoid denials for late filing.
• Automate reminders for resubmissions within permissible windows.

 

Best Practices for Reducing Claim Denials

 

Partner with Health Quest solution  for Clean Claims Submission

Health Quest Solution, a trusted leader in healthcare revenue cycle management, comes in. With our expert-driven solutions, your practice can achieve unparalleled accuracy and billing processes, and optimize reimbursement rates.

At Health Quest, we implement cutting-edge quality assurance measures to ensure every claim submitted is accurate and compliant with payer requirements. Our team audits claims identifies potential issues, and applies corrective measures before submission, reducing denials and improving your revenue cycle. 

Final thought:

In health care, Clean Claims Submission is not just about how to reduce denial issues but also about optimizing the revenue cycle. Healthcare providers can improve their revenue by partnering with Health Quest Solutions and focusing on their main goal of providing exceptional care to the patients.  Incorrect claim submission or any missing information can lead to claim denial; therefore, it becomes very necessary to submit a clean claim submission to ensure a quick reimbursement from the insurer. 

Feel free to reach out to us at (415) 508-653