Submitting clean claims is more important than ever for emergency medicine physicians these days. Declining fee schedules, changes due to procedure bundling and the growth of high-deductible plans all leave groups with little margin for error when it comes to cash flow. The pending ICD-10 code set transition could further strain collections, at least in the short term.
That’s why it’s critical for groups to develop policies that consistently produce properly documented and accurately submitted claims, according to Mark Canada, a regional vice president of operations for web2pro Business Performance Services (web2pro).

“There are so many factors driving reimbursement today that are beyond providers’ control,” Canada said. “So it becomes very important to use all available tools to capture every reimbursement dollar. Clean claims not only expedite payment but also decrease the back-end costs associated with working denials.”

Canada highlighted 10 steps that all practices can follow to generate clean claims:

  1. Clean claims start with good documentation of the patient encounter. Providing detailed documentation allows the coder to assign the most appropriate procedure and diagnosis code to support that encounter, which enhances the 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 the practice does its own coding or depends on a hospital or other external facility to provide procedure data, it is important to make sure that the charge master contains the most current version of CPT. Utilizing outdated codes is almost guaranteed to result in a denial.

  2. Know your carriers and their payment policies. What modifiers do they accept? 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. Staying on top of carrier policies requires a proactive approach. Billing personnel should monitor a payer’s website and correspondence, and also establish and maintain contact with the payer’s representative. A solid and productive relationship with the carrier representative will not only help the practice stay informed, but also can be very useful in resolving questions or issues.

  3. 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, the billing staff should challenge the delays and request interest on late payments.

  4. Make sure you’re operating with the most current insurance information. Verify demographic data, policy information and whether the insurance provided is primary or secondary. If insurance information is captured by a hospital, regularly check the crossover tables to make sure the carrier codes being used are consistent with the codes loaded into your billing system. If possible, your billing staff should have access to the hospital’s demographic database to conduct quick and accurate searches for missing or incorrect insurance files.

  5. Be sure that your billing staff is working insurance correspondence in a timely and effective manner. This can often help illuminate what information is missing from a claim and thus provides a critical link for payment processing.

  6. For hospital-based physicians who depend on their partner facilities to capture insurance data, allow for a five-to-seven-day lag time between the date of service and the transmission of the demographic file to your billing provider. This gives the hospital extra time to gather and verify critical information, particularly in instances when patients do not arrive with their insurance cards, such as an admission via the emergency department.

  7. Does your billing software utilize business rules known as edits to identify and flag problem claims that are missing information or have data elements that are inconsistent with billing conventions?

    For example, if a policy number for Aetna typically has nine characters and the number the hospital provides has eight, the claim will be stopped until someone can review it further. Edits can additionally help sort out local coverage determination issues to identify where claims may need additional information or codes. This can be especially useful for those claims that qualify for PQRS reporting. 

  8. Know which carriers require pre-authorizations and then develop a good system to capture this information on the front end. Hospital-based physicians typically rely on their referring physicians for obtaining pre-authorizations, and if the referring physician office does a poor job, the hospital group will suffer. Establish a system that allows you to accurately measure no-authorization denials so that you can provide timely feedback to the referring doctors and help them to modify their practices accordingly.

  9. Once a claim has been submitted and is accepted by the payer, it is important to understand the message codes on explanation of benefits statements (EOBs), since they can provide additional reasons for non-payment.

  10. Finally, creating an effective denials management system allows the practice to track and report claims while making adjustments to resolve non-payment issues. Most physicians are eager for documentation feedback, particularly if their work is triggering denials and negatively impacting the group’s revenue stream. Regular in-service events to bring physicians up to speed on payer changes or new documentation requirements can be an effective technique for minimizing clinical documentation problems.

    Feedback to hospitals, meanwhile, can influence the hospital’s leadership to improve data capture mechanisms, something that can benefit the hospital as much as the physician.

“Understanding in detail all carrier requirements – from documentation and pre-authorization to allowable claims and proper formatting – then applying this knowledge in an ongoing and consistent fashion frequently will spell the difference between payment and non-payment,” Canada said.


About the author

web2pro 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.