What Is a Clean Claim and How Can You Achieve It?

The medical billing and reimbursement process involves a complex interplay of patient care documentation, provider information, coding accuracy, and insurance adjudication. A clean claim signifies a well-structured and complete submission that meets the requirements for swift processing and reimbursement. Discover how you can achieve a clean claim and which benefits come with it.

Submitted claims for reimbursement are anything but simple and straightforward. With many facets of information and considerations across the revenue cycle, getting reimbursement can often seem like a much-deserved reward after an arduous process. Thankfully, there are ways to reduce the hiccups and setbacks in claims management. It starts by ensuring you’re submitting a clean claim.

Understanding clean claims

In healthcare billing, a clean claim is one that meets all requirements for timely processing and payment. It’s characterized by accuracy and completeness, which are crucial for both healthcare providers and insurance companies. Clean claims significantly reduce administrative burdens, expedite payment, and minimize claim denials and rework.

What does a clean claim look like? Typically, it includes the following information, verified for accuracy and completeness:

  • Patient information: Name, date of birth, contact details, and insurance information
  • Provider information: Name, National Provider Identifier (NPI), contact details, and billing information
  • Service details: Date of service, description of services rendered, quantity, duration, and unit charges
  • Diagnosis and procedure codes: International Classification of Diseases 10th Revision (ICD-10) codes, Current Procedural Terminology (CPT) codes, etc.
  • Supporting documentation: Medical records, test results, referral notes, etc.

With no room for mistakes, misinterpretation, or missing information, each of these data points must be correct, clear, and complete.

Benefits of submitting clean claims

Submitting clean claims is a tedious process, but it’s essential to mitigate the potential for denials. Prioritizing the integrity of early-stage revenue cycle management (RCM) steps such as preauthorization, charge capture, and medical coding goes a long way toward generating a clean claim — and the benefits associated with it:

  • Streamlined reimbursement: Submitting clean claims lightens the administrative load, leading to fewer follow-ups and a smoother workflow. This results in improved cash flow and financial stability for healthcare providers.
  • Faster processing and payment: Clean claims are reviewed and adjudicated more swiftly due to their accuracy and completeness. This translates to timely reimbursement from insurance companies — and a consistent revenue stream.
  • Reduced denials and rejections: Clean claims lower the risk of errors that can lead to claim denials. This reduction in denied claims results in a decreased need for appeals and resubmissions, as well as fewer claim write-offs.
  • Enhanced patient satisfaction: Fewer billing discrepancies and disputes arise from clean claims. This enhances patient satisfaction by fostering trust in the provider’s billing practices, ultimately contributing to a positive patient experience.

Strategies for achieving clean claims

Attaining clean claims requires a combination of meticulous documentation, effective technology utilization, accurate coding practices, and proactive internal audits. Here’s how to achieve it:

  • Improve documentation practices. Ensure thorough and accurate documentation of patient encounters to support well-substantiated claims.
  • Use electronic health record (EHR) systems. Optimize efficiency by utilizing EHR systems that integrate patient data and billing processes.
  • Ensure accurate coding and billing procedures. Maintain coding precision based on accurate diagnoses and backed by consistent staff training.
  • Audit for quality control. Employ regular audits to catch and address issues led by compliance officers or dedicated audit teams.

Strive for clear, consistent, clean claims

A clean claim is a golden ticket to quicker reimbursement. When your claim contains all the relevant information and is presented with accuracy and full context, it’s easier for payors to accept and process — and to issue reimbursement without any back-and-forth to clarify details or uncertainties. Keep this in mind as you seek to improve your revenue cycle management.

Learn more tips for clean claim submissions with TruBridge.