Imagine that your healthcare practice runs like a well-oiled machine. Every claim is submitted smoothly, and you rarely have any submissions kicked back for further review. Payments arrive on time, and your team stays focused on patient care instead of chasing down denials.
A high clean claim rate is the key to making this vision a reality. Learn what a clean claim rate is and why it’s critical to the health of your revenue cycle.
A clean claim is an insurance claim that is submitted without errors or other problems. To count as a clean claim, it must be processed and paid on the first submission.
Your practice’s clean claim rate is the percentage of claims that are paid without any issues. It’s a vital metric for your practice, as it directly impacts cash flow and operational efficiency.
A clean claim has all the essential information and sails through the payer’s system. There aren’t any coding mistakes — just a straightforward path to reimbursement. When your clean claim rate is low, delayed payments and increased administrative work cut into your bottom line.
The Healthcare Financial Management Association recommends setting your sights on a clean claim rate benchmark of 98%. The minimum rate to achieve consistently high practice performance is approximately 95%.
Want to make it easy to track your clean claim rate and other metrics? Download our ebook Claims Analytics: An RCM Gamechanger.
A high clean claim rate supports your success in the following ways.
Clean claims get paid more quickly. A low clean claim rate leaves you stuck in a cycle of follow-ups and delays that disrupt your cash flow. Keeping your submissions clean will promote claim denial prevention and ensure your team has time to focus on what matters: serving patients and growing your practice.
Improving reimbursement speed also leads to new opportunities. You’ll have the cash flow and financial stability necessary to build your practice, attract new clients, and expand.
Every time a claim is rejected, a team member has to stop what they are doing and rework the submission. This tedious process eats up staff time and increases your operating costs.
Whether you have aspirations of growing your practice or simply want to maximize revenue, cutting out waste is critical. Unnecessary administrative expenses should be at the top of your cost-cutting to-do list.
Fewer denials mean stronger relationships with insurance providers. On the other hand, consistent issues can weaken your leverage when negotiating contracts.
Payers are already working from a position of strength. Performing consistently throughout the year will help you level the playing field and may lead to more favorable contract terms.
A low average clean claim rate can be due to one (or several) underlying issues. Here are the most common culprits that may be preventing you from realizing your full revenue potential.
Incorrect or incomplete medical codes are a leading cause of claim denials. Mistakes here delay payments and demand costly rework.
Over time, coding error trends may emerge among each of your payer partners. With a modern revenue cycle management (RCM) solution, you’ll be able to track these trends and proactively address common coding errors that disrupt your revenue.
If a claim is missing basic patient information or contains errors, it will be flagged for rejection. In response, your team will have to manually review the claim and identify what information is missing or incorrect. All of that time would be better spent serving patients and processing new claims.
Simply skipping eligibility and benefits checks before submitting a claim can lead to denials. Make sure your team understands the importance of pre-submission benefits verification. Reinforce the concept that unverified claims waste time and resources.
Boosting your clean claim rate requires a proactive approach. Clean up your RCM claims with these best practices.
Train your team to use the correct codes for every service. Create a coding reference resource and ensure that it is easy to find. A searchable reference guide will encourage your team to double-check the accuracy of codes before submission.
Additionally, conduct regular audits and deliver ongoing education so you can catch errors before they become costly. Rivet Health’s tools help you streamline coding to minimize the risk of mistakes and capture more revenue.
Check out our list of medical coding tips for additional strategies that can improve your revenue cycle.
Manual patient information collection is inefficient and prone to errors. On the other hand, an automated approach drastically reduces the risk of mistakes.
Implement systems to collect and verify patient data up front. Review your existing processes and replace manual methods with automated alternatives wherever practical.
Use automation to simplify eligibility checks for confirming coverage and benefits before submitting claims. This protocol will prevent denials due to unverified insurance and keep your revenue cycle on track.
You should also track how each payer handles eligibility verification requests for the most common services and procedures you perform. If a payer frequently rejects or is slow to respond to eligibility requests, you can address that negative trend during your next round of contract negotiations.
Rivet Health’s suite of tools — Revenue Diagnostics, Payer Performance, Patient Pricing, and Claim Resolution — addresses each of the major pain points of revenue cycle management for orthopedics. With our platforms, you can:
Our platform offers seamless EHR/EMR integration and comes with top-tier customer support. Learn more about Rivet’s healthcare revenue cycle management solutions for orthopedic practices.
A high clean claim rate is the foundation of a thriving practice. Rivet Health’s Claim Resolution platform empowers you to track and manage denied claims efficiently, uncover concerning patterns, and prevent future rejections.
With seamless integration into all major EHR and EMR systems and industry-leading customer support, Rivet Health delivers the tools you need to maximize cash flow.
Are you ready to learn more about Rivet’s denial prevention software? Schedule a demo with Rivet Health!