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What is a clean claim?  

A clean claim is a successfully processed and reimbursed insurance claim. A clean claim has no errors, rejections, or need for manual intervention or additional data.  

Having a high rate of clean claims demonstrates an organization’s ability to capture and enter quality data the first time. Submitting a clean claim leads to quicker reimbursement and account resolution.

Criteria for a Clean Claim:  

1. A clean claim is submitted by a licensed healthcare provider.  
2. The coverage of a clean claim was in effect on the date that the organization provided the healthcare service. Also, the services covered must be under the patient’s health insurance.  
3. To eliminate questions on medical necessity, procedure codes must support the diagnosis codes.  
4. All the codes used on the claim must be current.  
5. All information must be correct and placed on the appropriate fields of the claim form.  
6. Accurate identification of payer, including the payer ID and the mailing address.  
7. The claim must submit it within a specified time.  
8. Any other required supporting documents are provided.

Why do Insurance Claims get Denied?  

Insurance companies have strict regulations. Furthermore, their standard operating procedures are ever-changing. Most of the time, claims get denied because of improper patient care, but there can be other mistakes like:

• Late submission of documents  
• Incomplete or insufficient supporting documents  
• Patient not eligible for services 

• Overlapping coverage dates 
• Missing pre-authorization/ pre-certification

Proven and Tested Ways to Increase Clean Claim Rate  

There are many possible ways to hit that industry’s best clean claim rate of 90%. To start, having thorough claims procedures is a must.   

Healthcare providers must keep up with the ever-changing rules that affect claim submissions. Furthermore, they must also review the claim denials and underpayments to unveil additional reimbursement delays. Also, they need to be sure that both the clinical and the financial staff communicate. Effective communication will ensure that everyone in the organization understands the part they play in revenue cycle management.  

From intelyHealth’s years of experience in the healthcare IT space, we have learned many ways to increase healthcare organizations’ clean claim rates. We have listed the top 3 that we have seen and proven to be successful.

1. Invest in the proper RevCycle management education and training for clinical and financial staff.  

Clinical and financial staff and all those who take part in the revenue management cycle must undergo proper education and training on the significance and impact of the clean claim rate. The entire organization should also know the common errors that lead to denied claims and the corrective action needed to address them.  

With well-trained staff and robust revenue cycle management software, all the needed data will be accessible. Healthcare organizations can extract information and analyze root causes. Healthcare providers can then put corrective actions in place to avoid future claim errors.  

While technology can enhance the efficiency and accuracy of RevCycle management, it can’t always substitute for the lack of trained staff.

2. Choose a reliable RevCycle management vendor.  

We have already proven that a clean claim rate is a significant metric of the overall performance of the RevCycle management of a healthcare organization. The technology they provide is why partnering with a vendor of RevCycle management solutions and services is a good investment.    

With a RevCycle management vendor, your staff can focus on more patient-critical tasks. With reliable technology in place, both clinical and revenue cycle staff members will capture required patient information during the patients’ visit.

3. Claim Scrubbing  

The choice of a scrubber and clearinghouse is key to high clean claim rates. Scrubbers and clearinghouses ensure that claim errors are immediately identified and resolved before submission to the payer. 

Scrubbers and clearinghouses are also essential because most major payers don’t allow direct claim submission from healthcare organizations. These rules ensure that payers only receive relatively clean claims from healthcare organizations. 

Increase your Clean Claims Rate with intelyFi  

IntelyFi CCR analysis provides automated and enhanced clean claim data.  

IntelyFi combines data from the clinical EMR, revenue cycle system, and claims scrubber/clearinghouse to identify the root cause automatically. IntelyFi increases your organization’s visibility and understanding to drive long-lasting improvements to your financial and operational health. 

IntelyFi simplifies the data and identifies where the problem occurred in the claim lifecycle. Through this enhanced reporting and automation, an organization can identify and correct operational and technical issues that negatively impact its clean claim rate.  

An improvement in clean claim rate can reduce FTEs, reduce the cost to collect, and accelerate cash.  

Ready to increase your clean claims rate? Contact us today and schedule a free demo.