What makes a claim "clean?" A clean claim is one that is never rejected. It does not receive any type of denial. It does not need to be filed more than once because of errors. When a claim is clean, it goes out your door, requires no additional work, and is paid.
Essentially all ASC key performance indicators (KPIs) are impacted by how fast the ASC can get claims out the door. If a claim is dirty (i.e., unclean) and takes an extended period to be paid, days in accounts receivable (AR), AR greater than 90, and denials are going to increase.
When you get out clean claims, staff productivity will increase. You may be able to reassign staff to other tasks or even reduce staff. You will save on the expenses associated with re-working claims, such as postage and printing documentation. Finally, having a high clean claim rate will help you hit all your ASC's financial objectives and be in a better position to stay on budget.
Follow these 10 tips to improve your ASC's ability to submit clean claims.
1. Engrain the importance of clean claims
For the reasons noted above and others, clean claims are vital to an ASC's financial success. Everyone involved with getting a clean claim out the door in a timely manner — from physicians to coders and billers — must understand the pivotal roles they play. Furthermore, they must understand and fully appreciate how shortcomings, especially those that are ongoing, can have significant short- and long-term effects on an ASC's viability.
2. Strive for 100%
Achieving a 100% clean claim rate is likely to be impossible. Even if an ASC does everything right with its claims all the time, payers inevitably deny claims. It's not unusual for an ASC to have a claim denied and then have that same exact claim processed upon resubmission.
With that said, there's no reason ASCs should not target a 100% clean claim rate, even if efforts will inevitably come up short. SIS Revenue Cycle Services' clients typically see an average clean claim rate of around 98%. What matters is working to improve every month. Scrutinize rejections, denials, and delays and then implement fixes to reduce the likelihood of these occurring again.
3. Develop detailed processes
There should be no question about any of the steps staff are expected to take to best ensure the complete, accurate completion of claims. Make sure your processes detail these steps but do so in an easy-to-follow manner. Help staff follow these processes by providing "cheat sheets" and other resources.
New staff members should be able to quickly understand the processes your ASC has in place and their responsibilities in completing these processes. Furthermore, address what staff should do if they have a question or concern about information for a claim. Staff should feel confident that every claim going out the door is as clean and complete as possible.
4. Be prepared to change processes
While detailed processes are essential, just as critical is your willingness to revise these processes. You should do so whenever payer guidelines and roles of team members change as well as when you identify problems and/or opportunities for improvement. Just because a process works now doesn't mean it will always work as well.
Do not hesitate to revise processes whenever you can make them better. Train staff when you change processes and monitor staff performance to ensure new processes are followed properly.
5. Hold staff accountable
For ASCs to maintain financial success, their business office must deliver consistent results. While one hopes that staff members will always perform their jobs to the best of their ability, holding staff accountable to following process and achieving objectives can help ensure a higher level of execution. If performance suffers, and efforts to turn matters around prove unsuccessful, staff must know there will be consequences.
6. Support staff
ASCs can help their staff succeed in their roles by providing ongoing support. This can take many forms. For example, ASCs can invest in sending team members to state or national meetings; allocate funding for certifications, online courses, and webinars; and purchase books, manuals, and cheat sheets. Ask staff what they need to improve their performance and succeed in their positions, and then do your best to deliver such resources. Even small investments in support can lead to significant returns.
7. Become technology experts
If your ASC has invested in technology to support its business office, do all you can to maximize that investment. Allocate time to learn the ins and outs of your solutions. There may be new features or older functions you are not using that can make claims processing more effective and efficient.
Speak with your technology vendors and ask them for guidance. You may be surprised to learn what handy tools are at — or will soon be at — your fingertips.
8. Seek out improvement opportunities
As has been emphasized a few times in this article, regularly assess your performance and processes, looking for weaknesses that can be strengthened. Likely, you will discover areas for improvement. If you do not, that's okay. You will at least validate that you have the best possible processes in place. However, understand, as noted earlier, that a process right for your ASC now may not be the right process down the road. Evaluate your processes and performance frequently.
9. Act fast if performance suffers
If your clean claim rate starts declining, don't wait to respond. Dive into your data and identify the cause(s). Is a single payer denying all of your claims or all claims associated with a single procedure or specialty? Are you receiving rejections for a new procedure's claims? Are denials and rejections on the rise for a specific team member? There are many factors that can contribute to a decline in your clean claim rate. Seek them out and implement fixes ASAP.
10. Succeed as a team or fail as a team
Getting out clean claims is all about teamwork. ASCs with the highest clean claim rate tend to have at least one thing in common: staff who work very, very well together. When staff not only work hard but support one another and hold each other accountable, an ASC's performance improves. But when communication is poor and business office departments operate as silos, with staff members only concerned about their own work, this will drag down revenue cycle performance and KPIs.
Focus on building a strong team and you're more likely to succeed. Just be careful: Allow even a little negativity to permeate your team and watch your processes and performance deteriorate. If you do not address that negativity effectively, your bottom line will take a substantial hit that may prove difficult to recover from.