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5 ways to ensure clean claims

March 5, 2015
by Julia Brown
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When it comes to filing insurance claims, a lot can go wrong. Coding errors and accidental omissions in information can ultimately delay payments to providers. Therefore it’s important for all stakeholders involved to strive for “clean claims” that are processed the first time around instead of the second or third.

Claims adjudication is meant to be an automatic function that accepts the claim, sorts the data with algorithms and then renders payment. Any uncertainty in the operation will cause a claim to be kicked out of the automated system and either denied outright or sent into a manual queue. Manual processing is more costly and time consuming.

In an effort to improve this processes, Behavioral Healthcare asked industry experts to weigh in on what providers are doing wrong and offer advice on what they would consider best practices for filing claims. Administration also needs to know how to best navigate a denial if it should occur.

Here are five tips for making sure your claims are clean and that your payments are rendered promptly.

1 Use technology to your advantage

Dawn Muller, executive director, Aetna Behavioral Health Operations, says filing electronically and signing up for Electronic Funds Transfer are two ways to help expedite the payment of claims right off the bat. 

“Currently, the majority of providers bill electronically and receive reimbursement through Electronic Funds Transfer,” says Muller. “Paper claims have not completely diminished yet, but they will continue to fade out over time and eventually become rare.”

Looking ahead, she says, there will be increased use of technology for contracting, claims payment and benefit quoting, as well as widespread use of electronic medical record. Providers should be prepared to abandon paper entirely. 

2 Make sure data fields are correct

Although coding errors vary, Muller says providing an invalid diagnosis code or an invalid member identification number are the two most common data field mistakes. Providers also frequently submit claims that are incomplete, she says.

Another common reason for claims denial is inaccurate information says Janna Aiken, director of billing operations for American Addiction Centers.  

“Make sure all information is correct, such as location of services—inpatient or outpatient—spelling of name, date of birth, address, insurance policy ID number and group number,” she says.

She adds that it’s important to double-check to ensure that diagnosis codes and authorization numbers match the level of care billed. If the claim form is missing modifiers, or if the modifiers are invalid for the procedure code, the claim is likely to be rejected in the system.

Also watch for insurers with similar sounding names or with distinct networks. Sending a claim to the wrong insurer won’t trigger a response, and the claim will languish until the provider ultimately realizes the error.

3 Avoid duplicate claims
Increasingly, more healthcare services are bundled into a single package, Aiken says. Paying close attention to this could prevent the wasted time of duplicate billings that aren’t necessary.

“For example, lab profiles with multiple tests don’t always qualify for separate reimbursements, or an all-encompassing rate may cover a minor procedure as well as the pre- and post-procedure visits,” she says. “In these cases, a combined payment is often received.”

Aiken says that one of the most common reasons a claim is denied is because of a duplication. However, it’s not always the trouble of bundled services but rather because a practice that hadn’t received reimbursement resubmitted. It’s important to be patient and wait before filing a secondary claim, she says.  Returning unearned reimbursement because of a duplicate payment could cause more administrative cost than the payment total itself.

4 Keep an eye on deadlines 
Don’t let anything slip through the cracks. If a claim isn’t submitted to the insurer within the permitted timeframe, Aiken says, it’s almost always rejected.

Many insurers don’t consider a claim to be received for processing until all information is complete and accurate. If a payer needs additional information to process the claim, it must be submitted before the deadline. 

The limit to file can be as short as 90 days from the date of service, Aiken says, so it’s important to clear up omissions and inaccuracies when initially filing. Essentially, have a buffer between when you file and the deadline so errors can be eradicated if necessary.

5 Don’t deny yourself the chance to review a denied claim
In the case of a denial, Aiken recommends allowing a window of  48 to 72 hours to do the legwork on the denied claim before responding or resubmitting.

“If you can figure out the missing or inconsistent information, respond to the denial within a week of its receipt and you have a good chance of still receiving payment,” she says.




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