Diagnostic provider leadership teams understand the importance of revenue cycle management (RCM) for maximizing reimbursement promptly. Submitting clean claims is one of the most important ways that a diagnostic organization can ensure payment in a timely manner from both private and government insurance payors. Receiving the maximum reimbursement the first time a claim is submitted is crucial to achieving desired operating margins.
How diagnostic providers define a clean claim varies significantly. Some consider claims clean even when they have no apparent errors on the front end even though they may ultimately result in denials in the back end. Allowing claims to be labeled as “clean” when they contain errors means that an organization will never have the analytical insights necessary to improve the quality of the claim information they receive. In its simplest form, a clean claim should be defined as one that has no errors or omissions and can be processed without additional information or verification of information by a human, third-party service, or automation. A clean claim contains all of the following correct information:
- Each procedure code has a supporting diagnosis code that is not expired or a deleted code
- There are no potential issues or questions regarding medical necessity
- The patient’s coverage was in effect on the date of service
- The patient’s insurance covers the service provided
- The claim submission includes all the required patient information such as full name, mailing address, and date of birth
- The claim identifies the payer, including the correct payer identification number, group number, and mailing address
- All required claim information is in the correct field
- The claim is submitted within the timely filing window
To measure how a diagnostic organization is performing when it comes to RCM, an important metric to track over time is the “clean claim rate.” This measure quantifies the rate at which insurance claims have been successfully processed and reimbursed the first time they were submitted. This means it contained no errors, rejection, or need for manual input of additional information. To achieve a high clean claim rate, organizations have traditionally had to work claims manually to:
- Retrieve missing patient information
- Correct errors or information in the wrong fields
- Validate insurance eligibility
- Follow up with physician offices for supporting information.
Submitting clean claims means the claim spends less time in accounts receivable, less time at the payer, and the laboratory or other diagnostic provider gets paid faster. Experts across the industry agree that a clean claim rate should exceed 90 percent. However, based on an analysis performed by XIFIN, specific to laboratory claims, approximately 35 percent of all diagnostic procedures have errors that need correction before they can be reimbursed. This translates to upwards of $20 billion per year in either delayed or permanently lost reimbursement in the US alone. XIFIN also found that 12 percent to 20 percent of all requisitions lack a payer-specific ICD-10 or other information resulting in partial or full claim denial. Many organizations choose to write off these uncollected claims rather than incur the labor costs associated with achieving a clean claim. In contrast, leading organizations are maximizing their clean claim rates and reducing their bad debt without an increase in labor costs by leveraging automation. Real-time connectivity and error correction, integrated patient demographic and insurance discovery, automated supporting document attachment, and portal-enabled patient and client communications all improve clean claim rates without human intervention.
