Question: How do I increase my clean claims rate and reduce my denial rate?

Answer: Implement a Pre-Bill Review process.

Most denials are caused by errors occurring on the front end of the revenue cycle. There are so many details involved with processes such as patient registration, eligibility verification, referrals and authorizations that making a mistake is not only possible it’s probable.

In a busy clinic with excellent people and perfect processes there will still be errors, and while some are preventable some just happen, and it is nobody’s fault. People paying attention to detail and double-checking their work helps but a Pre-Bill Review is the best solution.

What is a Pre-Bill Review? A Pre-Bill Review involves putting every Initial Evaluation through a 25-point inspection. This inspection should be performed by someone who knows and understands each of the pre-claims processes that can lead to delayed or denied claims.

Each practice determines which data points will be checked and errors are reported on a weekly/monthly basis to the other members of the team. This is not an opportunity for the back end to point fingers at the front end but rather an extremely important feedback loop that is needed for coaching and training purposes.

Examples would include:

  • Was the correct payer selected?
  • First Name
  • Last Name
  • Group #
  • Policy #
  • Referral/Authorization (Payer specific)

The clinic can change codes, modifiers, and diagnosis if your Pre-Bill Review is in-house but if it is a Billing Service they will have to forward coding, modifier, and diagnosis issues back to the clinic for review and/or change. The claim then circles back for another Pre-Bill Review and if all is well the claim goes out.

You are thinking “where am I going to find a resource to do a Pre-Bill Review?” Your question should be “How much time do I spend working on denied or delayed claims?” Putting the time on the front end eases your pain on the backend.

If you have a Billing Service, you will help them to help you by putting out clean claims that do not require additional efforts that ultimately delay those claims. It will keep your revenue stream consistent month over month.

Implementing a Pre-Bill Review will ensure your “First Pass Claims Rate” reaches and remains at 98%+ which in turn reduces preventable denials. The Best Practice for denials in a clinic setting is < 3% and this number is easily achieved using this process.