Great medical billing starts with great data collection and ends in clean medical claims. Great medical collections starts with clean claims and ends in maximum reimbursements.

Let’s look at the bridge between great billing and great collections:  The “Clean Claim”

A clean claim is the methodology used to create a billing form (typically a UB or HCFA) that is free of any mistakes.  The firm must be fully complete so the payer can process the information without the need to request additional information from the provider or any other third party.  The form must be totally correct from the first box to the signature.

A clean medical claim will cover all of the following:

  1.  The provider will be properly licensed within all state and federal requirements on the date of service. The provider may not be under investigation for fraud.
  2. Remember CPT (procedure codes) all need supporting diagnosis (ICD) code. If you have both it will eliminate objections by payers based on the medical necessity for the services being billed. This makes logical sense; but without being specifically required and taught the provider and their staff may assume the diagnosis is implied and not include all complete and proper, up to date diagnosis codes in their bills. Be aware of this problem.  Also remember, codes come and codes go.  With the advent of ICD-10 all diagnosis codes changed but some CPT codes are also no longer in use or relevant.
  3. Always makes sure the patient has available insurance for the date of service, not the date of billing. Then make sure the coverage is specifically available for the services being provided. Generally sub-specialists are more in danger of the later not being covered and haven’t claims denied.
  4. Look at all the initial boxes on the UB or HCFA twice.  It is easy to miss including Demographic information such as the patients date of birth, they are full legal name, their insurance identification number and/orThe claim form includes all the group number. You need to check this twice because now that most bills are posted electronically it is easy to have information shift into the wrong boxes due to computer error as much as human error. Having your billing agent remember to scan the demographic information before submitting the claim will help ensure that the full claim goes out as a perfected clean claim.
  5. Make sure that your claim properly names the correct payer. If you have called the payer to determine coverage make sure your billing agent obtains the correct identification number. Also, if paper bills are still required, as in personal injury protection (PIP) and or/Worker’s Compensation (WC) make sure you have the correct mailing address.
  6. Finally never wait to bill and make sure all claims are timely submitted.




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