The clean claim myth
Clean Claims, the myth! For over two decades, I have heard about the myth of clean claims and a clean claim rate of 98%. So I want to know if this rate of 98% truly exists, and if so, how it is achieved. This morning, while defining KPIs for a client, I audited claims and found instances that did not qualify as clean claims. NDC code rejections from a payer occurred because the fee schedule for that drug wasn't updated from the latest batch provided by the drug company. The payer rejected the NDC code because the fee schedule was updated, but the insurance company hasn't updated its list yet. Patient eligibility was rejected because the patient is a junior, and the clerk didn't add this information since it didn't occur to the patient to mention it. The senior has been deceased for years; why would you ask? The whole idea of "clean claim" is misleading. Are we focusing only on backend issues, or are front-end issues involved as well? Or are we considering ...