An efficient denial prevention process is based on the concept of clean claims. Your clean claim rate is the differentiating factor between denial prevention and appeal management. Ensuring clean claims is critical to your bottom line. Why? Clean claims are 1:1, dollar for dollar, every time. The farther a claim is in the denial process, the more expensive it is to resolve. Your organization will spend time and money appealing claims that depreciate the longer they’re appealed; that’s a waste of time and effort. Some sources report the industry standard clean claim rate anywhere from 75-85% but recommend striving for closer to ninety percent.
If you want to improve your organization’s clean claim efficiency, shooting for 90% immediately will be overwhelming; thankfully, you don’t have to do it alone. Instead, let’s discuss key best practices and recommendations to improve your clean claim rate.
Clean Claim Rate Factors
Many denials are the result of inaccurate front-end data. Patient registration and patient care are two significant points that can be under or incorrectly documented. How do you eliminate potential errors? This can seem complicated as registration and care utilize many moving parts.
Your RNs and administrative staff are on the front end, and one of their jobs is to capture patient information quickly and efficiently. Ensure your front-line staff has sufficient training and knowledge to capture data, even if it means verifying patient demographic information at every encounter.
Payers are updating their policies constantly, so keeping staff updated on payer policy information is also important. Does the payer cover screening exams? What are their policies for multiple procedures being performed at the same time? Your staff should know the answers to these questions and use that information proactively to combat preauthorization and eligibility. Understanding coverage policies and submission requirements is important, as all documentation must support the level of care to pass through the revenue cycle unscathed. Unfortunately, payer policies are not one size fits all. Even deadlines differ greatly from payer to payer, leaving utilization review staff in a difficult position.
Front-end staff is your organization’s first line of defense in data gathering. Traditionally, front-end staff had to review each claim manually to work up an appeal. Manually reviewing claims is a long, tedious process. Thankfully, the era of manual reviews is going the same way as typewriters and VHS tapes, thanks to new technology and automation.
If the constantly evolving technology landscape is too time-consuming or overwhelming, outsourcing may be a viable option. Outsourcing ensures your organization increases its clean claim rate and maximizes revenue without increasing internal workload.
How Advent Can Help
Advent Health Partners breaks down our utilization review process into three categories: prior authorization management, concurrent reviews, and pre-bill reviews. The utilization review process uncovers opportunities to improve organizational management, eliminate oversight, and create systemic processes to ensure maximum revenue recovery. Advent Health Partners works as part of your team to complete more utilization management reviews, reinforcing your organization’s denial prevention strategy and letting your clinical team do what they do best: patient care.
To discover how Advent Health Partners can increase financial recoveries and operational insights for your hospitals or health system, please connect via the button below.