Episode Transcript
Speaker 0 00:00:02 Hello, and welcome again to our revenue radio podcast, powered by CAOU and company CAOU healthcare solutions, where we enhance the business of medicine. Hey and welcome back to our CAOU revenue radio. But today we have with us, uh, a colleague of mine as the executive director of UHU healthcare solutions. Uh, I also have our director of revenue cycle management, and that is Marty Sanders for, I'm glad to have you back with us today. I'm glad to be back. All right. Uh, you know, we've talked, um, various, uh, episodes on AR days and different things, aging and such. So I thought we'd bring in another really hot topic. It keeps everybody awake, clean claims, <laugh> clean claims, clean
Speaker 1 00:00:53 Claims. Yeah. The golden measure of revenue cycle. There
Speaker 0 00:00:57 You go. It's one of the top, uh, lines on our metrics reports. Is it not?
Speaker 1 00:01:01 That's correct. Yeah, that's correct. It is the, uh, the standard,
Speaker 0 00:01:05 Right. So Marty has, uh, has got a lot of experience 30 years or so in didn't mean to, um, let everybody know that you started when you were 12 that in revenue cycle that's, but, uh, Marty's got significant experience in revenue cycle management, billing collections on the healthcare side, you know, we're part of revenue radio. We want to bring this good quality information to our physicians, our physician practice owners. Uh, we want to help our, you know, your colleagues on the billing side as well as practice managers. So as we think about clean claims state, why is it so important to think about a clean claim? How does that fit within the revenue cycle? What does it mean? Kind of give us some thoughts, uh, as it relates to that, please.
Speaker 1 00:01:55 Sure. Well, by definition, a clean claim is any claim that, um, has no errors has no missing information. If documentation is required when the claim is filed, that that documentation is not omitted from that mm-hmm <affirmative>. So there is nothing standing in the way from providers being reimbursed timely by payers for the submission of those claims. So nothing standing in the way, no barriers, that's a clean claim. Okay.
Speaker 0 00:02:28 So let's make sure we understand this. This is, this is the responsibility of the practice or the biller to have it all right before it goes out.
Speaker 1 00:02:38 Absolutely that's as it's going out. That is the goal. Yeah. Most, um, practice management systems PM systems mm-hmm <affirmative> or clearing houses measure their clean claim rate by what they call a first pass rate. Okay. Meaning that when the click is made for the electronic claim, we'll talk about electronic claims to be filed to the payers that there is nothing standing in the way, no predetermined error messages, missing, um, policy number, subscriber, date of birth, missing things like that. Nothing that will keep that claim from getting to the payer. And if it gets to the payer for adjudication, even though that doesn't mean it's gonna be paid most PM systems and clearinghouses consider that a clean claim.
Speaker 0 00:03:31 So adjudication that's a big word,
Speaker 1 00:03:33 Big word, big word.
Speaker 0 00:03:35 Yeah. Where is that in the process?
Speaker 1 00:03:37 So when the payer receives the claim and it goes into their system, that big adjudication word means, uh, it's pretty much being judged. Okay. Whether or not you are, that's a great, yeah. A worthy of payment. Yep.
Speaker 0 00:03:49 There you go. So, uh, us old timers and we remember that red HFI yes. 1500. Yes. Uh, and I know it applies to the, the UB as well on the, on the hospital side, but now it's the CMS 1500, I'm thinking of all those boxes. Everything's got a number you're telling me that on the electronic side, all of those boxes are, are completed.
Speaker 1 00:04:20 That's correct.
Speaker 0 00:04:21 From an electronic file.
Speaker 1 00:04:22 That's correct. And instead of box 33, you may have a loop 2200 and segment something. Okay. Uh, a lot of technical terms, right. Most PM systems have all of that, uh, worked into their software. Okay. So you don't have to worry about that. Right.
Speaker 0 00:04:39 Um, now will, uh, and again, to, to get through all of the controls, get through all the, the hoops to get it out the door, uh, virtually or electronically, uh, we've gotta be thinking about, like you said, dates of birth, all of the demographics, places of service, all that, that that's all provided by that EMR is that, or the practice management system,
Speaker 1 00:05:05 Correct. That's correct. And most people, um, associate claims with just billing, but your clean claim actually starts with your first encounter with the patient it's, um, making sure that eligibility is checked and that they do have coverage and that it is active coverage. Uh, it, uh, begins with getting the copy of the insurance card mm-hmm <affirmative> and then making sure that that policy number is entered correctly in that the, uh, effective date that you have, the right insurance. Yeah. Um, many elderly patients have gone away from your traditional, what we call red, white and blue Medicare, correct. Mm-hmm <affirmative> and have, uh, opted for Medicare advantage plans yet they may present at the physician's office with just their traditional Medicare card mm-hmm <affirmative>. And so if you check eligibility on that, it may come back as active, but you have to know how to read that eligibility to see that they are active Medicare, but that they have a Medicare advantage plan. So capturing that information, subscriber information, all of those demographics, that's the very start of your clean climb.
Speaker 0 00:06:18 So my mind's going all kinds of different scenarios, but we'll, we'll just take, so let's make sure eligibility is not the same as prior authorization.
Speaker 1 00:06:26 It is not. Okay. No,
Speaker 0 00:06:28 Talk to us real quick about the difference of that.
Speaker 1 00:06:30 So eligibility is the check, um, that most practice management systems can do this electronically. Sometimes you have to pick up the phone and call the insurance mm-hmm <affirmative> number on the back of the insurance card, call the carrier itself. And that's to make sure that this insurance is active, that it is effective and that it is applicable to your practice. Right.
Speaker 0 00:06:52 So really you couldn't even get to a prior authorization without an eligibility,
Speaker 1 00:06:56 Correct? That is correct. All
Speaker 0 00:06:57 Right. Good. So then, uh, you know, again, the systems and, and the good thing, you know, we're what on 10 or 11 systems or something like that, something like that, we're pretty agnostic to, yes. These practice management systems we're able to get in and get out and do what we need to do. Uh, you're you're preparing a claim, you've got a particular diagnosis and the CPT code doesn't match really the, the body part <laugh> right. Uh, what do you do in that case?
Speaker 1 00:07:30 Well, you don't send that claim out.
Speaker 0 00:07:32 Does the system find that? Or
Speaker 1 00:07:34 Sometimes, yeah, it depends on the practice management systems. Mm-hmm some are more sophisticated than others and they will have some pre-checks or pre scrubbing as you know, that may be what they call it. And it can give you a list of those edits, some systems you have to actually print a report of those claims that are going out for the day and have someone look at those claims, you know, uh, not only does the diagnosis match, but are the appropriate modifiers on there. And so those things all need to be checked.
Speaker 0 00:08:08 So, so Marty, it, the, the report that you're describing, is it, uh, telling you how many say claims are not ready to go out because there's some error, what kind of describe what you might be looking for on a, on a report or for our listeners? Uh, those are they're participating with us. What should they be, uh, talking to their EMR, their practice management vendors, and such about reporting to help them see this so that they're not duplicating efforts, they're not sending unclean claims, um, and maybe, maybe help us out there on what that report's showing.
Speaker 1 00:08:54 Sure. So, so some practice management systems will have in their claims processing, uh, an error report and they are built in errors. Sometimes it's just the vendor that has put those error messages in their system. Uh, some practice management systems will allow you to add to that. And so you can get an error listing or a flags of these claims are not clean and it will take some type of intervention. Yeah. Sometimes you can just look at the medical record and see that there was a diagnosis that is valid in there and just put it on the claim. Right. As long as it's in the documentation, right. You would never put anything on a claim that is not documented. Sure. Right. Uh, other systems have reports that you have to go in and tweak. Yeah. And, uh, we have one system where we have, uh, pretty much marked all of our things that we wanna look at for that specialty. Right. And so that, that report is printed and it's looked at every day and it prints all of the claims and we look for the errors.
Speaker 0 00:10:03 Okay, good. And others might have what I call the buckets. You can go to another screen and it's got a dashboard of some sort that's right. I guess the point being is be familiar with the practice management system. Yes. Yes. You don't know something, just pick up and call your vendor,
Speaker 1 00:10:21 Know your, know your practice management system and know your payers. Yeah. And what their requirements are.
Speaker 0 00:10:26 Yeah. Yeah. Good. Um, so it's important. It's a, you know, we kinda look at it and blow, but there's, there's lag time. There's timely filing issues and such that all go into preparing that, that claim. So it can go out clean. What, what are, tell us a little bit about what your thoughts are on lag times. Who's, who's responsible for lag times. What's the timely filing portion of this. Maybe someone's new, that's starting into this field. What do they need to know about timely filing?
Speaker 1 00:11:06 So there are carriers who say, if your, if your claim, if your provider's claim is not adjudicated in our system within 45 days of the dates of service within 90 days of the dates of service, then we're not gonna pay you period. Mm-hmm <affirmative> and there is nothing you can do to get past that. Yeah. And so timely filing is very important. So you start on the, again, everything starts at the beginning and it is communicating with your providers and telling them, informing them of these things. And also having a relationship with your providers that if they're not closing their notes in the EMR, or, you know, for those who still have paper charts, they're not giving you their charge ticket. Right. Uh, timely. You have to give them that feedback. Yeah. Because that's costing them money. It, right. It has a potential of costing them a lot of money. So that's the, the first part, the second part is knowing that we have to file claims. We file claims every day for all of our clients. I don't wait for a week to file claims. Yeah. Yeah. We file claims every day and get those out the door. If the carriers don't get the claim, mm-hmm, <affirmative>, they're not gonna pay you. That's
Speaker 0 00:12:20 Right.
Speaker 1 00:12:20 That's right. They're not gonna do
Speaker 0 00:12:22 It. We gotta, we gotta start that revenue process as soon as is as possible.
Speaker 1 00:12:28 That's right.
Speaker 0 00:12:28 And it's getting the claims out the out door. Right. Right. Good. So what are some of the metrics that you use to sort of gauge, um, how things are going from a clean claims perspective?
Speaker 1 00:12:43 So again, most practice management systems and clearing houses gauge if it gets through those front end edits without a rejection mm-hmm <affirmative>, which I call easy fixes. Yeah. Um, then that's a good clean claim rate. Okay. And you want your clean claim rate to be above 95%,
Speaker 0 00:13:01 95%.
Speaker 1 00:13:02 Right. Um, I prefer them at 99 to a hundred. Um, and so if you see that you're getting those rejections and those front end edits, then you need to look at those and see if there are patterns. What is the problem? It could be as simple as you've hired someone new, right. Um, at the front desk and they may have been trained in everything, but, but one part, right. And they may not understand something and they don't know what to ask if they don't know. Right. And so it could just be saying, all of a sudden we're getting all of these rejections and we have this person new mm-hmm <affirmative> so it's a training issue. So that's the easiest fix. Once those claims are adjudicated, um, then it becomes a little more costly, right. And a little more, um, difficult to correct. Yeah. And by costly, I mean, the studies have shown it's an average of $25 per claim to rework that claim.
Speaker 0 00:14:06 That's hard cost.
Speaker 1 00:14:08 If you get a hundred, 100 claims in a busy practice, a hundred claims is nothing that could be three days worth of patience. Sure. Office patients. Sure. Yep. So if you get 20, uh, 100 claims that have denied from the payer, there's $2,500 at cost yep. Out the door. Yep. And so it's very important to get those.
Speaker 0 00:14:29 Yeah. It's uh, if you think about it, if I've gotta rework it and clean it up to get it clean, to get it out, that's time, I'm not able to spend calling patients on their statement balances that's right. Follow up, whatever the other parts of the cycle are. Um, I mean, we've seen it, we've taken on new clients and such that had issues. And, um, we, we had overtime and things that we had to deal with just because their clean claims weren't where they need to be. And it was a, it was a correction process, right?
Speaker 1 00:15:03 Yeah. It's been reported that 50 to 65%. Wow. Of denied claims in most practices are never worked.
Speaker 0 00:15:13 Wow.
Speaker 1 00:15:14 And the reasons are people say they don't have time or some just don't know how to fix them.
Speaker 0 00:15:20 Yeah.
Speaker 1 00:15:20 Okay. And so when you get those, the way to identify them are two ways. Uh, and, and they usually go along with each other is, uh, denial codes or remark codes on your remittances. Mm-hmm <affirmative> if you get a remittance and it says at the end of it, the total check is zero. That's a problem. Yeah. Because that means I've gonna write you a check for nothing. That's right. And I don't wanna check for nothing's.
Speaker 0 00:15:47 Right. Yeah. We call those the zero pays the low pays or the no pays.
Speaker 1 00:15:51 Right. And, um, that, to me, those are the most important remittances that I get. Mm-hmm <affirmative>, I mean, I love to get large remittances with lots of money on it. Right. But that means I got paid. Right. So those are good. Right. But the most important are your zero pays because that is where the insurance carriers telling you, I'm not gonna pay you. And here's why. Yep. And so those need to be worked most practice management systems. Again, should have some type of report on your denial code or your remark code, run those reports by carrier. See what your patterns are. Are you getting a lot of non-covered services for one provider? If so, then we need to take that back to your provider and, and say, they're not paying this. Mm-hmm <affirmative>, it's, it's it's non covered. Is there another appropriate code that is covered? Are we missing something here? If there is, then you definitely use that code. If there's not, then you are giving your provider the information needed to know whether or not that service is absolutely necessary for his patients. And if it is, then it's a cost of taking care of patients. Right. And most providers are okay with that. Right.
Speaker 0 00:17:10 Let's you know, get it right. Get it out the door. If there's a, if there is a, a discussion or a perception or one of those kinds of things that we gotta go back and forth about as you know, was this the right care, right. We'll argue that all day long with letters and
Speaker 1 00:17:30 Deals and such,
Speaker 0 00:17:31 But when it comes right down to the real basic blocking tackling, not just making, it's not getting the boxes completed, but having them done right. That's, that's where a real quality RCM team, uh, can, can help a practice.
Speaker 1 00:17:46 That's exactly right. Yeah. Yep.
Speaker 0 00:17:48 Uh, anything else that, uh, that's, you know, from a words to the wise kind of deal, and, uh, as it relates to clean claims and, and revenue cycle,
Speaker 1 00:17:59 I think that just letting all staff know that everyone plays a part, everyone plays a part from the person who answers the phone, who takes the first insurance bit of insurance information to the person at check in getting that information, uh, in entered into the practice management system, accurately to the providers documenting appropriately documenting everything that they did, getting the notes closed timely. Yep. Getting that to your billing office, the billing office, the reviews, the front end checks, getting those claims out daily, and also those who receive the remittances and post payments and your follow up every single person is vital. Yeah. And has vital information and input to have your clean claim ratio. That's a stay up and you get paid timely for your services.
Speaker 0 00:18:57 Right. That's, uh, that's really important. We can always look at those technical things, but that, that just, um, the marriage of your, of your team yes. And how they work together and just how fluid it is and understanding each other's processes and functions are, are so important. Well, Marty, thank you so much for being with us today. Um, we hope everyone out there picked up a, a nugget or two out of our discussion, if nothing else, a a, a good solid reminder of how the clean claims function and component of the full RCM process that's right. Can enhance and maximize their, their business. So this is Jeff dance. Uh, thank you again for being a part of our Caso revenue, radio, uh, program and podcast. We hope you'll be back with us next time, where we look to enhance your business, your medical business, and maximize your revenue. Thank you.
Speaker 2 00:19:59 Thank you for tuning in to the CAO podcast network resources for today's episode are linked in the episode notes. Thank you to our producer Russ Dorsey and for CAO, for powering this podcast. Be sure to stay up to date on new episodes and more information about today's episode by following at CCO until next time. Thanks for tuning in.
