The approach by which patients get medical services and healthcare providers are paid for those services is known as revenue cycle management in the healthcare industry. In revenue cycle management (RCM), legitimate claim management is extremely important. A clean claim has been submitted to a payer, such as an insurance provider or government healthcare program, without any mistakes or problems. Clean claims promote healthcare organizations' financial stability and sustainability as a crucial part of the revenue cycle. As a result, inaccurate and falsely submitted dirty claims greatly cost healthcare providers.
We should be prepared to deal with many obstacles when we strive for a clean claim. A claim form is used to file medical claims and must be filled out completely. Demographics of the patient, information about the provider, dates of services, precise coding of diagnosis (ICD-10), procedure (CPT or HCPCS), modifiers, and any additional pertinent information, such as eligibility confirmation, prior authorization, or referrals that the payer requires.
When submitting a claim, certain insurance companies could ask for further evidence to support the medical need. Medical records, progress notes, and other pertinent paperwork are included in this documentation. We can back up the medical condition by enclosing the necessary paperwork.
Every payer has a specific deadline within which they must get medical claims from providers. To prevent a denial (Untimely filing), medical claims must be submitted within the time range specified by the payer.
Electronic claims submission
Payers prefer electronic claim submissions because they decrease mistakes associated with paper claims filing. Providers should utilize the proper electronic claim submission format for each go-through, depending on the payer's preferences.
Claims must adhere to all relevant billing laws and regulations and payer-specific policies after being updated with all the precise claim information, precise coding, and quality assurance processes. Only complete or correct information may result in claim denials, payment delays, and administrative costs.
Impact of Clean Claims over RCM
Clean claims are handled by payers more swiftly and efficiently. Because clean claims are uniformly pre-filled with all the necessary information, payers may examine and approve them more quickly. As a result, the revenue capture process moves more swiftly, allowing healthcare organizations to receive payments more promptly.
Low claims denial
Getting rid of or drastically cutting down on claim denials is one of the critical goals of submitting clean claims. Clean claims are less likely to contain errors, omissions, or inaccuracies that might lead to rejections. The presentation of clean claims is the most excellent strategy and methodology for decreasing denials. Understanding the reciprocal link between clean claims and rejection avoidance can help healthcare providers navigate the complicated world of revenue cycle management with improved efficiency and financial stability.
Reduced admin cost
Additional administrative responsibilities typically accompanying rejected or denied claims include correcting errors, resubmitting claims, appealing rejections, and following up. Clean claims mean less work for the office workers and cheaper expenditures.
Clean claims enable healthcare providers to get payments more quickly and consistently. The delay between service delivery and payment receipt must be shortened for providers to manage their finances more efficiently and pay for overhead expenses like equipment and technology and operating costs like payroll.