Implement coding and billing best practices right now.
Stop chasing denials. Submit claims cleanly and confidently with strategies that protect revenue.
Protect revenue before it’s at risk
While claim denials can happen for many reasons, most are actually preventable. The key is to take a proactive approach. Identify the root causes early and put fixes in place. Denials often stem from eligibility or authorization issues, incomplete clinical documentation, or missing or invalid claim data. But it’s just as important to empower your team to hold payers accountable when needed.
Providers need to shift from defense to offense to protect their margins and stay ahead of constantly changing payer-reimbursement requirements. One recent trend that providers are seeing is increased payer scrutiny of medical necessity to deny claims. That’s why R1 uses advanced analytics and algorithms to help clients spot diagnostic codes that payers are most likely to deny.
Top 5 denied diagnostic codes
- A41.9 – Sepsis, unspecified organism
- J96.01 – Acute respiratory failure with hypoxia
- N17.9 – Acute kidney failure, unspecified
- G93.41 – Metabolic encephalopathy
- E87.1 – Hypoosmoality and hyponatremia
See what counts as a clean claim
A generally accepted definition of a clean claim is one that payers can process and pay the first time it is submitted. While back-end denials management is an important component of revenue capture, the first-pass resolution rate is a strong indicator of how effective revenue cycle processes are from front to back. Follow these 10 best practices for submitting clean claims the first time.
10 best practices to keep claims clean and cash flowing
While incorrect coding in a claim will almost certainly lead to denial, coding itself is only one piece of the clean claims puzzle. Administrative deficiencies can also lead to denied claims. It’s strategically important to take a holistic approach to claims management that prioritizes clean claim submission. Here are 10 things you can do to help code and bill clean claims.
- Keep patient information updated. Patient data is subject to constant change. Outdated information can trigger denials. That’s why it’s critical to confirm or update basic information like addresses, phone numbers, employer and insurance plan at every patient encounter.
- Verify eligibility and authorization before the date of service. It’s mandatory for submitting clean claims, but it still accounts for about a quarter of all denials. It’s also labor-intensive process that can reduce staff capacity. With labor shortages as the new normal, leveraging a technology partner with healthcare RCM expertise that supports the financial-clearance process helps avoid excess front-end denials.
- Provide detailed clinical documentation. Few things are more critical for clean claims than documenting the actual services provided so they can be properly coded and billed. But with more payers challenging claims on medical-necessity grounds, clinical documentation takes on even greater importance.
- Keep an eye on the calendar. Failure to file claims according to the specified payer terms and timelines makes even an otherwise clean claim an easy target for denial. Regular reviews of timely filing and pending claims should include a check of submission deadlines to help prioritize work queues.
- Double check modifiers to ensure correct usage. Coding modifiers need to be applied correctly and to the correct procedure. The National Correct Coding Initiative has useful tools for providers to help ensure medical coders are using modifiers correctly and efficiently.
- Follow payer-specific coding guidelines. Different payers can have different coding guidelines that are specified and required. Creating payer-specific Local Coverage Determination guidelines will help coders verify compatibility.
- Implement quality-control checks. Claim scrubbing should be a required step in any submission process. Technology can make these quality-control reviews more efficient and effective. Providers can go a step further by employing analytics across RCM departments to identify denial trends and determine root causes. Prescriptive analytics can go further still by providing guidance on how to resolve identified issues.
- Maintain the chargemaster. As the final authority on service fees, the chargemaster needs to be maintained to reflect Centers for Medicare and Medicaid Services updates, pricing changes, and new procedures and drugs. Quarterly updating is recommended.
- Find opportunities to automate. Claims management involves a considerable amount of manual, repetitive processes that can easily be automated. This can not only increase staff capacity and shorten cycles, but it can also reduce transcription and other data errors.
- Know and track your KPIs. Providers have a variety of metrics available to help them understand the current state of their claims-management processes. Clean claims rate and first-pass rate are two of the more useful for measuring performance in this area, but denials rate and other indicators are also helpful.
Take the smart path to strong reimbursement
Health systems find themselves besieged by the financial woes of escalating costs and a reimbursement environment that seems to create new challenges every day. Preventing denials and prioritizing clean claims to payers is important for accelerating and optimizing revenue.
The R1 Platform brings the power of AI, Intelligent Automation and Deep Data Analytics to denials recovery and billing. Modernize your processes with advanced technology.
Click here to learn more about R1 Platform.
