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 both? 

Just this week, I was discussing denied claims due to benefit max on a patient. The office called the payer and was told the patient had coverage and there were no issues. The client scheduled the first visit two weeks out, and everything was fine. However, two weeks after the initial visit, we received a denial for benefit max, and by the time we addressed the rejection, a second denial came in. Meanwhile, the office had seen the patient three more times. 
Could this have been avoided? If they questioned the patient further, but maybe not. He was seen at a different office a few months back, but that office closed, and it took a few weeks to find another with an opening. The real issue is that from the time the office called for insurance verification to the time the patient was seen, the office that closed down finally got their claims filed and pushed his visit count over the limit. 
These delayed denials can be caused by various other reasons, such as: 
  • Patient's coverage terminated retroactively
  • They switched to a different plan mid-month
  • COB information changed
  • A different provider filed first for the same service
To wrap this up, I feel that the industry needs to change its vocabulary: "clean," as in "could be processed without additional information," is not the same as "will be paid." A claim can sail through initial processing and still land in medical review, get bundled unexpectedly, or be denied for medical necessity. 
The reality? There's no such thing as a truly clean claim until it's paid. 


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