What Does Your Payer Dictionary Have To Do With Clean Claim Rate?

Many business offices, working toward an optimally efficient, cost-effective claims process, set a Clean Claim Rate (CCR) goal of at least 95%. A high CCR means less time and expense associated with getting accurate charges billed as soon as possible following the discharge of services.

Clean Claim Rate (CCR), the ratio of claims that pass edits cleanly—not requiring any correction or manual work prior to transmitting to payers—is an important indicator of your revenue cycle performance.  A high CCR generally demonstrates that at each point through the revenue cycle to the point of claim creation, data collection has been accurate and efficient.

Procedure and diagnosis coding, modifier use, and compliance with medical necessity rules are a few of the common trouble spots that can negatively impact CCR. One that often goes unnoticed is the state of your payer dictionary.

Insurance information entered during patient intake may or may not match an appropriate entry in your system’s payer dictionary. Claims entering your system with an unmatched payer name will cause a drop in your CCR and payment delays.  Worse, claims that have been tagged with the wrong payer identifier can result in rejections, denials, incorrect reimbursement, or even unauthorized PHI disclosures.

Is potential revenue leaking from the holes in your payer dictionary?

Plug the holes by keeping your payer dictionary up to date and your claims matched accordingly with regular weekly maintenance.  When matching or confirming insurance payer entries to each appropriate payer dictionary entry:

  • Be certain to match, in every instance possible, to a payer ID set up for electronic claim submission. Sending claims on paper unnecessarily is too often the result sloppy payer matching.  One consequence will be delayed payment; a lack of tracking on either the claim or payment may also result.
  • Confirm that the payer ID is a perfect match, so that the right claim edits are applied and the claim will be submitted to the correct insurance payer.
  • Choose to apply Medicare edits for a commercial payer’s Medicare product, or Medicaid edits in the instance of a commercial payer’s Medicaid product. If the only edits applied are those that would be appropriate for the payer’s commercial plans, important rules could be missed that could result in rejections, denials, or incorrect reimbursement.
  • Don’t forget to select whether or not “shadow” or information-only claims should be generated to the MAC when a Medicare Advantage plan is being billed for inpatient services.
  • Link your payer entry to the appropriate Line of Business so that the ANSI 837 Filing Indicator will be correctly completed in the claim that goes to the payer.

Having the correct payer designated by your system when a claim is generated is critical to making the most of the claim edits library in your claims management system.  Payer specificity is key to 2 of the 5 “Must Haves” for a high-quality claim edits library.  When that library includes all of the Five Must Haves—the success of your high CCR will be amplified with a high First Pass Rate (FPR) for the fastest, most reliable cash flow possible.

5-Must-Haves-Claims-Edits-e-book-coverRead about all 5 of the Must Haves for Your Claim Edits Library in our latest e-book Or, to hear more about how the Quadax FPR of 99.6% can improve your cash flow, get in touch—we’d love to talk.

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