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Crystal Miner, MBA-HSA, FACMPE

This is a series of 12 blogs written at the request of CodeQuick to help Medical Practice Administrators optimize the revenue cycle within their practice. Please contact C Business Services if you have any questions or would like more information.

A claim is an invoice that the clinic submits to a payer to get paid for the services (charges) performed. Most payers require that the invoices (clams) be submitted to them be in a certain format. Some require that if the invoice contains a specific service (charge) that additional documentation should be submitted. Administrators must have someone on their staff who is aware of these requirements. In addition to these requirements, individual states have their own rules regarding these claims. Knowledge and the preparation taken in the steps prior to this are the only ways to optimize this step in the revenue cycle.

To receive payment from a payer in a prompt manner, clinics must submit a claim free of mistakes and errors. This is usually termed submitting a “clean claim.” 42 CFR 447.45 defines a clean claim as one that needs no additional documentation from the service provider or third party. Below is a list of links to state’s insurance codes regarding claims. Almost all states now have some sort of “prompt payment” regulation. Some of these regulations have definitions regarding clean claims that are to be submitted to insurance companies. Those marked below do not have a specific definition.

 

One way to assure that claims are clean (free of error) when submitting them is to utilize a claim scrubber system that may be part of the clinic’s EPM or clearinghouse. This system will also be able to track the number of claims that need to be edited and resubmitted. Administrators should review the relationship with their current clearinghouse. Many of these services now offer additional benefits that are at no additional or little cost to the clinic. These include reporting systems, like a claims scrubber, that allow managers to track submission rates, claim errors, and claim edits. Administrators and managers should be using this data to monitor and improve their claims submission processes.

To assure that claims are as error-free as possible, all of the steps before this must be optimized first. By monitoring errors and edits, administrators can determine the root cause. Once determined, additional training, coaching of staff regarding appropriate workflows or attention to detail, removal of ineffective staff or hiring of additional staff or contractors can occur. The main contributors to these edits and errors are typically

  • Registration (demographic/insurance data),
  • Credentialing of provider with insurance,
  • Eligibility verification (was not done, patient ineligible, or no prior authorization), or
  • Encounter documentation or coding.Administrators and managers must work diligently with their staff to assure that the claims submission process is as smooth as possible. This is the last step before payment can be received. Claims should be submitted daily as soon as the documentation (with signature) and coding is completed. Once submitted, verified for lack of errors, and received by the payer, claim status should be checked often. Billing managers and team members should be able to tell administrators the expected turn around of claims. Claims which have not been cleared via payment or notification of the reason for non-payment by payer by the time expected should be researched immediately. Clinics should never wait for a payer to tell them the status of a claim. Clinic billing teams should know the status of all outstanding claims and be able to report on these to the administrator.By assuring that the steps prior to this in the revenue cycle have been optimized, there should be few edits and errors in the claim submission process. The edits that do occur should be tracked and reported to determine if there are any patterns. Billing teams must be aware of payer rules regarding claim submissions including formats and additional documentation requirements. Administrators who have completed all of these steps in the process are able to move their focus the next step in the revenue cycle.