5 Tips for Achieving Clean Claims in Specialty Practices

Clean claims are essential to practice revenue, yet may be difficult to achieve. Here, we discuss tips to effectively achieve them – read on!

When it comes to the financial health of any specialty practice, one of the many elements that have a major role is submitting accurate and timely claims. A clean claim is a claim that is accurately coded, properly documented, and submitted in a timely manner. A practice should aim for a clean claims rate of 95% or higher. 

Most practices do receive reimbursements the first time a claim is submitted—about 75-85%. However, about one-quarter of claims are denied or delayed because there were errors or incomplete documentation. For providers of specialty practices, achieving clean claims can be especially challenging given how complex billing procedures are, changing payer guidelines, and denial-prone claims.

If a practice's clean claims rate is less than 85%, that practice's staff is likely spending extra time identifying reasons for denial, corresponding with payers, and submitting claims for the second or third time. Achieving the clean claim acceptance rate benchmark is not just important for minimizing the cost of claims processing but for maximizing revenue as well.

When specialty practices focus on key areas and implement best practices, they can significantly improve their claims processes.

The Importance of Accurate Documentation

Ensuring effective clean claims submission - Male doctor training his female medical staff.

Thorough, accurate clinical documentation provides the essential foundation for clean claim submission in specialty practices. Documentation substantiates the medical necessity and appropriateness of procedures performed. Complete details in the medical record also enable precise coding of rendered services. Unfortunately, poor documentation quality continues to hinder many practices.

To improve, specialty providers can follow a few documentation protocols including:

  • Utilizing templates with mandatory fields and prompts to capture all relevant details specific to their specialty.
  • Documenting precise start and stop times for procedures billed based on duration, like infusions or psychotherapy, is important because accurate time increments impact the codes that are used for billing.
  • Ensuring descriptions clearly justify medical necessity for services billed. Records must also tell a full story linking presenting symptoms, diagnoses, tests, and treatments.
  • Requiring finalization and review of documentation for completion within 24 hours of patient encounters to reduce potential errors from late additions.
  • Hosting regular training refreshers for specialty physicians and staff on proper documentation requirements. 

Proper Coding and Its Impact

It's important to ensure coding accuracy for clean claims and revenue integrity. The International Classification of Diseases (ICD-10-CM) codes define the patient's diagnoses that justify the services given as medically necessary, and Current Procedural Terminology (CPT) codes show the services provided to the patient.

Since specialty services require specific codes to accurately reflect diagnoses and procedures performed, having specialist coders with niche experience is crucial. They will understand the ins and outs that generalist coders without said expertise may overlook or miscode.

A few effective coding strategies include:

  • Establish a compliance workflow where coders must verify documentation adequately supports the codes selected prior to finalizing claims.
  • Set routine internal audits of high-risk or problem-prone codes to detect where added training may be beneficial to boost accuracy. 
  • Maintain coders' skills through continuing education on updated guidelines as regulations and standards evolve.
  • Use coding audit software that analyzes common trouble spots and flags improbable or improper code combinations before claims release. 
  • Review for accurate application of modifiers that give important details to payers. Modifiers inform payment rates and improper use prompts claim rejections.

Timely and Efficient Claim Submission

Due to such a strong reliance on Current Procedural Terminology codes with immediate reporting requirements, specialty claims must meet tighter initial submission deadlines imposed by contractual payer rules. Any practice that does not transmit claims within filing timeframes will likely face rejections, leading to intensive resubmission and appeal processes. Delays also mean specialty practices face extended waits for reimbursement.

The keys to timely submission are:

  • Providing clerks and coders status updates and reminders as claim submission windows approach. Simple alerts help claims flow smoothly versus falling through the cracks.
  • Standardizing workflows and schedules to prevent backlogs. 
  • Consistent procedures for registration, documentation, coding review, claim finalization, etc.
  • Transmitting claims electronically for faster delivery and confirmation over manual paper claims prone to mishaps. 
  • Having an action plan for quick correction and refiling of claims rejected for errors or omissions. 
  • Entering claims into billing systems promptly after visits.

While the demands of specialty practices make timeliness even more challenging, establishing disciplined workflows and monitoring performance metrics around aging claims pave the way for specialty practices to meet or exceed submission targets consistently. The rewards of successfully submitted clean claims are healthcare providers receiving payment for their services in a timely manner and avoiding revenue loss due to claim denials or rejections.

Preventing Common Errors

A team of medical professionals having a discussion in a hospital setting.

Submitting clean claims is not just about accurate documentation and coding. In fact, even minor claim defects unrelated to clinical documentation and coding can instantly derail clean submission. Common sources of rejection include incorrect patient identifiers, inaccurate provider numbers, duplication, as well as clerical oversights. So yes, one small mistake can lead to claim rejection and a loss of revenue for your specialty practice.

Here are some examples of mistakes that can cause claims to be rejected:

  • Mismatched patient names, dates of birth, or insurance subscriber IDs between visits. Upfront verification and insurance card scanning reduce mismatches.
  • Outdated provider identifiers or using group versus individual NPI numbers. Regular checks ensure data aligns with networks.
  • Failure to add specialty-specific procedures and billing modifiers needed to settle certain services correctly.
  • Duplicate claim submissions that waste payer resources. Consistent processes and claim editing software prevent these.
  • Transposed procedure or diagnostic codes that scramble key details. Double verification of data entry increases accuracy.
  • Timely filing breaches when claims are not transmitted within short submission deadlines. Tracking aging claims provokes action.

Billing Software and Technology

Since these claims can be highly complex, capable billing systems and automation are key partners for specialty practices that want to submit clean claims. However, finding the right billing software and technology tools that are aligned with your practice's needs requires a bit of thoughtfulness.

Features to look for include:

  • Specialty-specific workflows built into the software reducing setup needs. 
  • Advanced code auditing to flag improper codes or invalid combinations before claim transmission.
  • Payment rule engines that screen claims against requirements and identify red flags before submission for correction. 
  • Reporting and analytics to catch deficiencies, pinpoint root causes, and focus training. 
  • Cloud hosting for universal accessibility and convenience. 
  • Scalability to support claims volume surges and data storage needs. 

Handling Claim Denials and Rejections

Preventing errors from the start is naturally the priority for clean claims. However, despite best efforts, claims will still face rejection or denial eventually. Accepting some failure rate as inevitable rather than an unexplainable oddity is helpful. The question for specialty practices will eventually become how soon they can identify problem claims and implement fixes moving forward through disciplined auditing approaches.

A few helpful strategies include: 

  • Comparing rejected/denied claims rates against established practice or payer benchmarks to gauge performance.
  • Analyzing the exact rejection/denial reasons given and categorizing them by cause—clerical, procedural, clinical, etc. Patterns will uncover vulnerabilities.
  • Prioritizing audits by claim type, billing code sets, as well as service lines with the highest rejects/denials to make the greatest impact.
  • Sharing metrics from claim audits during staff meetings illustrates where opportunities exist practice-wide to improve.
  • Highlighting examples of outstanding clean claims versus defective ones as teaching moments to onboard new staff faster.
  • Integrating audit results into continuing education planning to address any uncovered gaps.

Continuous Training and Education

Clean claims processes - Female doctor interviewing a female senior patient for accurate claims submission.

Knowing the detailed nature of specialty billing protocols, ongoing education, and training is a must-have if your practice wants to embed sustainable habits. Clean claims rely on billing teams keeping skills and know-how aligned to the latest industry rules and payer requirements even as regulations and technology modernize. There must be renewed learning across the revenue cycle, from clinical documentation to claim submission.

Tactics to maintain strong skills include:

  • Watching industry resources for important specialty billing updates and monitoring payer websites for newly published policies. 
  • Scheduling regular educational sessions as standards get updated. 
  • Adding continuing education on documentation, coding, and billing requirements to staff professional development plans and company education budgets. 
  • Aligning bonuses and performance management to clean claims rates that were achieved to emphasize its importance.
  • Putting together peer discussion groups between practices to share what has been learned. 
  • Celebrating and promoting training completions to recognize the billing team's dedication to education and self-improvement.

Turn to BillFlash RCM for Clean Claim Expertise

Clean claims are essential to practice revenue, yet difficult to consistently achieve given the nature of billing rules. Diligence in documentation, coding, submission timeliness, error prevention, specialty software choices, and continuous training of billing teams all work together to improve clean claims rates.

For specialty practices in need of elevated, optimized billing quality, and revenue integrity, BillFlash RCM has billing experts for every specialty to achieve clean claim rates well above industry standards. 

Schedule a demo today!

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