How CHM Helps You Reduce Claim Denials with Clean Claims Submission

Introduction

The healthcare landscape is continuously evolving, and one hurdle that remains for RCM teams and providers is claims denials. Each denied claim translates into increased administrative costs, lost or delayed revenue, and patient dissatisfaction. As a forward-thinking company, Velan has implemented a strategic clean claim submission process, significantly lowered denial rates, and ensured steady cash flow.

Here’s how we do it—and how you can put similar claim denial extinguishing tactics to work for you.

Why Do Claims Get Denied?

To develop effective claim denial reduction strategies, the first step is to understand the common reasons for claim denials. In addition to delaying reimbursement, claim denial increases the administrative burden of revisions and appeals. A few key factors account for the majority of denials.

Misinformation and incomplete information of patients

Payers can quickly deny applications with incorrect basic demographics — misspelled names, incorrect policy numbers, or bad addresses.

Incorrect or Inconsistent Medical Coding

Filing inaccurate CPT, ICD-10, or HCPCS code(s) can result in mismatched claims and denials. These often stem from poor documentation or obsolete coding knowledge.

Insufficient Authorization or Referrals

Many procedures and treatments require pre-authorization or a physician referral. If these steps are missed or the documentation is insufficient, the claim is potentially at risk.

Failure to Meet Filing Deadlines

All payers have specific deadlines for submitting claims. Even the most precise claim may be rejected if it is submitted after the deadline.

Claims That Are Duplicate

Resubmitting a claim without addressing the original denial reason can result in a duplicate, which is automatically rejected.

Inadequate Documentation

If medical records do not support the services billed, payers may deny using the reason “not clear” or ”not medically necessary.”

Most of these issues stem from avoidable front-end process errors, poor documentation practices, and a lack of communication with internal departments. This is why we make operational workflow optimization one of the key aspects of our solution for medical billing denial management.

CHM’s Strategies for Clean Claims Submission

Clean claims are achieved through methodological processes and tested systems that go beyond traditional goals. In a systematic way, based on healthcare RCM best practices, a process of resolution on claim quality step by step is put in place. The following strategies are critical to ensuring first-pass resolution:

Checking Eligibility and Pre-claim Verification

We review every person’s eligibility and benefits before rendering a service or submitting a claim. We confirm active coverage, check co-pays and deductibles, and secure any required pre-authorizations or referrals.

This Preventive measure ensures that claims are not denied for eligibility-based complications, which is one of the common claim denial reasons that can be avoided and will lead to a smooth healthcare insurance claim processing activity.

Accurate Medical Coding and Documentation

Clinicians and invoicing experts will work closely together to ensure accurate medical coding and documentation. Our certified programmers work on the latest coding guides and software tools to ensure high-quality results.

• A variety between the corroboration and the hryvnia codes
• Using Modifiers Correctly
• A clear representation of medical need

Process consistency also benefits from internal audits or real-time feedback channels, leading to improved compliance and accuracy.

Automated Edits and Usability Verifications

Our clean claim submission procedures utilize sophisticated claim editing software that also captures errors before submission. This system analyzes each claim for

• Fields that are incomplete
• Inaccurate code combinations
• A lack of modifiers
• Payer-specific data formatting guidelines

These validations occur in real time and serve as a check on potential fraudulent claims, blocking viable claims from reaching the payer and reducing the need for costly rework.

Relevant Staff Training and Accountability

Our organization invests heavily in training its employees to keep up with the latest updates on coding standards, payer guidelines, and federal regulations. All of the team members who work on healthcare insurance claims processing go through training on the following:

• Unique payer specifications
• Coding modifications
• Standards for documentation
• In particular, claim protocols without contamination

Key performance indicators (KPIs) Tracking and accountability are included at every step in the process to ensure consistency and excellence.

Track Submissions and Filings In Real Time

Timeliness is indispensable. An internal schedule guides strict adherence to each payer’s file deadline, which is supported by submission-tracking systems to prevent lost claims. The scope of workflows is as follows:

• Log submissions
• Real-time alerts about pending or rejected claims
• Timeliness parameters are routinely reviewed across payers.

By ensuring deadlines are met and all attachments are submitted and verified, we greatly reduce the chances of denials based on late or incomplete submissions.

Proactive Denial Management

In medical billing, denial management is no longer waiting for claims to be rejected and then taking action as a viable option. The time has come for a preventative approach to curtail denials before they happen, not to mention ensuring that fewer denial cases are managed at the highest level of effectiveness and efficiency.

This is how our denial management team ensures continuous improvement in claim results:

Analysis of the Causes

Every denied claim is a lesson in what not to do. A simple resubmission of a claim or appeal is never considered without a rigorous analysis of the underlying cause. Was it a software error? Missing documentation? Does that mean there is a payer-specific requirement? Through root cause analysis, we can identify systems of interacting causes that may not be visible at a cursory glance, allowing us to not only address symptoms but also prevent errors from recurring.

Getting Ready for and Following Up After the Appeal

For erroneous or reversible denials, we provide thorough appeals with supporting documentation as well as timely follow-up. To maximize recovery, we track appeal status and engage in payer outreach when necessary. This process is a critical component of efficient insurance claim processing in the healthcare sector, where the distinction between lost and recovered revenue can be determined by follow-through.

Feedback Loop for Training and Systems

The knowledge we acquire from denied claims is not restricted to a single area. The insights are provided to the training team, coding staff and frontend personnel. This end-to-end feedback system ensures continuous improvement of our clean claim submission process, thereby significantly reducing the likelihood of future errors at the entry point.

By making sure to proactively manage denials as part of an integrated approach, CHM creates a healthier revenue cycle, faster reimbursement, and fewer denials, using each denial as a catalyst for systemic change.

Best Practices for Clean Claims

To build a denial-resistant billing operation, we follow a truly practical, scalable, and proven set of healthcare RCM best practices. Whether you’re a small provider or a large health system, these strategies help optimize medical billing and claims administration processes:

The first place to do accuracy of the data is the initial contact.

Clean claims and clean data are interdependent. Person demographics, policy information, and validation needs must be truthfully anticipated during the registration process. A single digit or missing ID can derail the whole claim.

Regularly Train Staff on Documentation and Coding Updates

Medical codes, payer policies, and invoicing regulations are in a state of perpetual flux. We ensure that all personnel, from the front desk to billing, remain informed and compliant by fostering a culture of continuous education. Such an environment is a critical component of claim acceptance, as it facilitates precise medical categorization and documentation.

Use automated claim scrubbing tools

Automating the clear claim submission process speeds up the process and reduces human error. We use advanced scrubbing tools that detect errors, omissions, or inconsistencies before the claim is submitted, which greatly improves the percentage of first-pass success.

Monitor and Adapt to Payer-Specific Denial Trends

Each payer has its norms and patterns of behavior. By trending denial by payer and service, we are able to tailor our approach, thus reducing denials through the use of historical data. This focused approach makes a huge difference in reducing claim denials for us!

Establish a Closed-Loop System for Denial Resolution and Learning

We do not just fix denied claims; we learn from them. The denial insights feed the staff training, documentation guidelines, and coding audits. This comprehensive methodology contributes to the sustainable enhancement of insurance claim processing in healthcare and prevents the recurrence of errors.

Concluding thoughts

Denials are not an inevitable aspect of healthcare invoicing. Providers can substantially decrease their denial rates by adhering to a rigorous commitment to accurate documentation, clear claims, and ongoing improvement. Using our proven approaches to reduce claims denials, we provide a bankable road map for efficient, error-free accounting work.

Is your aim to improve your clear claim rate? At Velan, we can help you transform your claim processing journey with our intelligent, scalable RCM solutions.