Clean Claims Rate
In healthcare revenue cycle management, a “clean claims rate” refers to the percentage of claims submitted to a payer (such as an insurance company or government healthcare program) that are processed and paid without any errors or rejections on the first submission. In other words, it measures the efficiency of the claim submission process and how well a healthcare provider organization or medical billing company is able to submit accurate and complete claims that meet the payer’s requirements.
A clean claim typically meets the following criteria:
- Accuracy: The claim contains accurate patient information, including demographics and insurance details.
- Completeness: All required fields and documentation are included with the claim, such as the diagnosis and procedure codes, medical records, and supporting documentation.
- Timeliness: The claim is submitted within the specified time frame mandated by the payer, which can vary depending on the type of insurance and regulations.
- Compliance: The claim adheres to all payer-specific rules and guidelines, including coding and billing regulations.
- Validity: The services provided and billed for are medically necessary and supported by appropriate documentation.
A high clean claims rate is essential for healthcare providers and billing organizations because it can lead to faster reimbursement, reduced administrative costs associated with claim resubmissions and appeals, and improved cash flow. It also helps minimize delays in revenue collection, which is crucial for maintaining the financial health of healthcare organizations.
Calculating the clean claims rate involves dividing the number of clean (error-free) claims by the total number of claims submitted and then multiplying by 100 to express it as a percentage. For example:
Clean Claims Rate = (Number of Clean Claims / Total Number of Claims) x 100
Healthcare organizations often track this metric closely as part of their revenue cycle management efforts to identify areas for improvement and optimize their claims submission processes.
Zero Touch Rate vs. Clean Claims Rate
A clean claim is one that leaves the office “clean” (without errors) and is paid timely. But how much work did the claim require before it left the office? When coordination of benefits and coding are done right the first time, back-office work effort is “zero”.
Clean claims may still require back-office assistance before submission which requires touches to the claim and human intervention. This drives up labor dependency in your revenue cycle. You cannot determine how much work effort was required on a claim – even a clean claim – without a workflow automation solution added to the EMR/PM system that measures every touch.
Zero Touch | Clean Claims | |
|---|---|---|
Work Effort | Workflow automation tells you how many claim “touches” from the back office were necessary to get paid | Can’t be tracked. Clean claims may still require “touches” from the back office before being sent to the clearinghouse. |
Responsibility | Front office patient financial clearance is responsible for over 50% of denials. Zero Touch Resolution Rate indicates that back office medical billing department spent no time processing the claim | Back office medical billing department may still be spending time and effort making sure these claims go out clean the first time and get paid |
Drive down labor dependency with Effective Intelligence
Review and assess your practice’s financial status in 5 min or less and know exact where you are losing money and why. Measure the work effort of every revenue cycle employee, incentivize and retain your top performers, and help employees that need improvement.
You can prevent most common denials, rejections and write-offs during the scheduling and pre-registration process in advance of the appointment. Configure checkpoints and use central task management to quickly clear patients and keep your front office staffing needs at a minimum.
- Medical Coding Automation
Aligning the power of the MedEvolve Coding solutions with your internal resources personalizes and trains the autonomous coding model, increasing the speed that auto-codes are generated. The portal workflow also drives operational efficiency, resulting in repeatable and scalable performance.
As team members log in to the web-based application and record each “touch” of a claim, outcome, and next task, key data points are recorded like who completed the task and when, outcome, task notes, internal / external messages sent, collection success and other data points that feed into our real-time analytics.
