Have you ever tracked the percentage of claims that get paid successfully at first submission? To be successful with the medical billing process, the claims have to be monitored & revised, the reason for denials have to be correctly identified, and necessary action to be taken before getting started with the process. Here is all about claim submission in medical billing and steps to achieve clean claim rates.

What Is Claim Submission?

Submission of medical claims is one of the crucial steps in the medical billing process. The claim submission is defined as the process of determining the amount of reimbursement that the healthcare provider will receive after the insurance firm clears all the dues. If you submit clean claims, it means the claim spends minimum time in accounts receivable on the payer’s side, resulting in faster payments.

The average percentage of claims that get paid successfully at the first submission decides the clean claim percentage. In common, it is important to maintain this percentage level high for running a profitable healthcare practice.

Steps To Achieve Clean Claim Submission Rate

1. Ensure updated patient information on claims

The patient demographic information is at the heart of the clean claim. Updated patient records are very essential for the quality healthcare delivery for your patients. The maintenance of accurate and up-to-date patient information and health records can make all the difference to the outcome. So the very first step is to ensure updated patient information on claims. The information such as insurance policy data, patient demographics, and medical information should be thoroughly verified by your practice staff for submission of claims.

2. Verify patient eligibility earlier

Verifying patient eligibility at least two days before the DOS (Date Of Service) will help in better claim submission and lesser claim denials. This eligibility verification process also helps healthcare practices to maintain an effective cash flow through improved patient care and decreased write-offs. The information need to be verified in this step includes co-pays, deductibles, policy effective dates, in-network/ out-of-network benefits, and other requirements.

3. Manage pre-authorization requirements

Reduction in prior authorization-related denials ensures that there are reduced claim denials and improved cash flow. This should be done at least 5 days before the DOS. Make use of the best system that accurately captures pre-authorization information on the front end and allows your billing team to timely measure denials for “no-authorization”. This ensures that timely feedback can be offered to the healthcare provider.

The information need to be verified in this step includes the type of procedure, checking which procedure requires prior authorization, and verifying if that is procedure is covered under the patient plan.

4. Remain updated with medical coding regulations

Insurance claim denials and claim rejections are some of the biggest challenges affecting medical reimbursements. It is also too complex for the healthcare providers to remain updated with the medical coding guideline and regulations.

Outsourcing the claim submission process to the top medical billing companies will help you to stay up to date on all medical coding changes, ensuring your claims are coded correctly before submission. The claim denials often occur due to the incorrect coding or late submission of claims. Here, the process of claim scrubbing identifies the errors in coding immediately and resolves them quickly before submission.

The healthcare practices can also make use of the automation process called electronic claim submission by implementing the best medical billing software to process claims faster. The information need to be verified in this step includes ICD & CPT compatibility, the type of submission process (paper-based or electronic claim submission) to verify the coding compatibility.

RELATED: HOW ELECTRONIC CLAIM SUBMISSION SPEED UP YOUR CLAIM PROCESS?

5. Know your payers & ensure correct modifier usage

Do you know what modifiers do the payers accept? If their software does not recognize a modifier correctly, then it may lead to rejected claims. So it is better to understand what payers will cover and what they won’t. The information you need to verify includes the application of the correct modifier and appending the modifier on the correct procedure.

6. Perform quality checks to ensure clean claims

It is always advisable to perform quality checks to ensure the clean submission of claims in the medical billing process. The information to be verified includes demographic errors, medical coding errors, and errors that occur during the process of submission.

7. Maintain proper medical documentation

A well-documented medical record can facilitate effective RCM and reduce any hassles related to claim to process and ensure reimbursement. Some experts also said that proper reimbursement almost depends on good medical documentation.  Here, the information that needs to be verified includes patient medication history, procedure documentation, case history, and other medical documents for faster claim processing

Final Thoughts

The claim submission process is considered to be very important and at the same time a time-consuming task too. So, the above steps can be utilized and modified based on the needs of your practice growth.

As we all know clean claims lead to faster reimbursement, what is the best solution to achieve it? Outsourcing the submission of claims to the best medical billing service provider like CapMinds will increase your clean claim rate, reduce your overhead costs and ultimately improve your practice revenue.