How to Achieve a 95% Clean Claims Rate


Do you know what your practice’s clean-claims submission rate is? Because if it’s not currently 95% or above, you’ve got work to do.

Claim rejections are costly. Anything lower than a 95% clean claims ratio means you’re definitely losing revenue and furthering your expenses by having to rework those rejected claims. In reality, most practices have a rate that varies between 75% and 85%, which means that somewhere around 15–25% of claims submitted each month have to be worked on twice (at minimum). It’s like taking four steps forward and always having to take one step backward right after.

The question is: how can a 95% clean-claims submission rate be accomplished? Here’s what we suggest:

From contact information to insurance carriers and more, there’s a lot of patient information that can change—and quickly. With inaccurate patient data being a lead cause of denied claims, it’s crucial to have patients confirm or update their current information prior to receiving services. To help verify patient information in advance, use precise documentation to avoid delays and be sure to have patients update their forms at every visit (or even sooner with automated reminders).

Patients who visit a provider frequently are usually the ones staff assume have no recent changes to their insurance. However, those are often the source of most denied claims. One step toward a 95% clean claims rate is to collect and confirm every patient’s primary, secondary and even tertiary insurances at least five days prior to their scheduled service.

Simultaneously, it’s important to confirm any in- or out-of-network benefits, copays or deductibles as well.

Another way to help boost your clean claims rate is to ensure you have the most detailed medical information possible. This includes proper documentation of procedures, case history, medication history and other similar information. These documents can be used as supplemental records to process claims if needed.

Filing claims usually requires submitting within a tight window. And any time a claim is submitted outside of that window means an increase in denied claims.
If your goal is to have a near-perfect clean claim ratio for your practice, one of the best ways to do that is to pay attention to claim deadlines, and if there are any issues associated with patient coverage prior to their date of service, resolve them so the claim is not submitted late. One best practice is to aim for authorization between three and five days prior to service.

When it comes to your modifier usage, it’s important to verify that you’ve applied them correctly and to the right procedure. One way to help ensure this is done efficiently is to create a guideline of customized National Correct Coding Initiative (NCCI) edits for reference.

When your practice has clean claims, the result is faster reimbursements—and ultimately more revenue. Following these tips can help you reach your goal of a 95% clean-claims submission rate.


Photo courtesy of: NCG Medical

Originally Published On: NCG Medical

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