Submitting clean claims is more important than ever for physician practices. Declining fee schedules, changes due to procedure bundling and the growth of high-deductible health plans all leave groups with little margin for error when it comes to cash flow. 

That’s why it’s critical for groups to develop and maintain policies that consistently result in properly documented and accurately submitted healthcare claims, according to Debra Lyon, a director of revenue cycle operations for McKesson Business Performance Services. 

An industry leader in physician billing services and revenue cycle management, McKesson Business Performance Services bills for more than 30,000 healthcare providers annually across multiple specialties, helping practices manage their revenue cycle and improve overall healthcare financial performance.

“There are so many factors driving reimbursement today that are beyond providers’ control,” Lyon says, “So it becomes very important to use all available tools to capture all charges for services provided and any claim/billing defects are identified and resolved promptly. Clean claims not only expedite reimbursement but also decrease the back-end costs associated with working denials.” 

Lyon offers the following eight steps to clean healthcare claims that can make the difference in your practice’s ongoing financial health:

1. Start with good documentation of the patient encounter.

Providing detailed documentation allows your coders to assign the most appropriate procedure and diagnosis code(s) to support that encounter, which enhances your practice’s ability to get paid for the service. Information should include not only the specific diagnosis and details related to procedure or service but also the patient history. 

If your practice depends on a hospital or other external facility to provide procedure or diagnosis data, it also is important to make sure that the charge master and diagnosis listing contains the most current version of the CPT®, HCPCS and ICD-10 codes. Utilizing outdated codes almost guarantees a denial.

2. Know your payers and their payment policies.

You need to know the answers to these questions: What modifiers do the payers accept? Should you use a –50 modifier for a bilateral procedure, or a combination of –RT and –LT? If their software does not recognize a modifier, it could lead to rejected claims. 

Also understand what a payer will cover and what they won’t. Do they cover screening exams, and if so, how often? Do they apply payment reductions when multiple procedures are performed in the same session? Staying on top of payer policies requires a proactive approach. 

On behalf of clients, McKesson billing personnel make it a habit to monitor payers’ websites and correspondence, and they also establish and maintain contact with payer representatives. This solid and productive relationship will not only help everyone stay informed but also can be very useful in resolving questions or issues.

3. Manage pre-authorization requirements for each payer.

Establish a system that captures pre-authorization information on the front end and also allows your billing team to accurately measure denials for “no-authorization” so that timely feedback can be provided to the physician.

4. Know your state’s payment rules.

Some states have clean claims payment rules that require all clean claims to be paid within a certain amount of time. If the payer is not operating within these requirements, your billing staff should challenge the delays and request interest on late payments.

5. Regularly verify patient demographic and insurance information.

This patient demographic and insurance information is at the heart of a clean claim. Your staff must be instructed to verify it at every encounter in order to maintain an efficient revenue cycle.

6. Include notes in designated claim segments or attach records to clarify/support the services provided when necessary.

Payers are notorious for denying claims for medical necessity or delaying payment for review of medical records. It is important to monitor their patterns of behavior and develop processes to preempt reimbursement delays by providing concise, supportive notes in designated claim segments or associating paperwork (PWK) with initial claims.

7. Be sure your billing team knows your billing software better than the software vendor itself.

Your billing team should be taking full advantage of efficiency features offered by top billing systems, including deploying several levels of business rules known as edits or bridge routines to identify and flag (“scrub”) problem claims that are missing information or have data elements that are inconsistent with billing conventions. Edits can be specific to your organization, to payers, or to formats such as ANSI 5010, and can dramatically improve the rate at which claims can be submitted with very little human intervention. 

McKesson’s billing teams are familiar with most major software systems and work on behalf of clients with their specific system, improving the quality of claims submitted and the speed of clients’ revenue cycles as a standard practice.

8. Create an effective denials management review process.

Most physicians are eager for documentation feedback, particularly if their work is triggering denials and negatively affecting the group’s revenue stream. Regular in-service events that bring physicians up to speed on payer changes or new documentation requirements can be an effective technique for minimizing clinical documentation problems.

“Understanding in detail all payer requirements, from documentation and pre-authorization to allowable claims and proper formatting, then applying this knowledge to create a clean claims submission process will spell the difference between speedy payments or delayed payments, or in some cases even non-payment,” Lyon says. 

McKesson Business Performance Services provides healthcare organizations with as much – or as little – help as they need to help optimize all areas of the revenue cycle, including patient access, coding, charge capture, compliance, medical billing and accounts receivable management. Learn more about physician revenue cycle management services and how we can help your practice grow revenue and maintain positive cash flow. 

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McKesson

About the author

McKesson Business Performance Services offers services and consulting to help hospitals, health systems, and physician practices improve business performance, boost margins and transition successfully to value-based care.