Clean Claims Data: Why It’s Key to Successful Value-Based Care
Written by: Will Barnett, Senior Solutions Manger, Veradigm, and Cheryl Reifsnyder, PhD
Clean claims submissions have long been essential for practices aiming for rapid reimbursement from payers. However, as the healthcare industry transitions to value-based models, claims data have taken on even greater importance.
The goal of value-based care is to achieve better patient outcomes at lower costs. However, measuring success for such a massive goal requires data for benchmarking key measures such as patient outcomes, rates of preventive care, and various expenses. This type of information is found in claims data.1
Claims data is also crucial to the success of value-based care because it can be leveraged to help improve patient outcomes and to help reduce overall costs—both primary goals of value-based care. For instance, claims data can improve patient outcomes by helping providers identify and address gaps in patient care. Claims data can help decrease healthcare costs by reducing administrative burden and speeding reimbursement.
However, for claims data to support the shift to value-based care, it needs to be complete and accurate—which is why clean claims submissions are crucial to value-based care.
Clean claims challenges
What, exactly, does “clean claim” even mean?
Clean claims include comprehensive and accurate patient information: patient demographics, procedural and diagnostic coding, insurance details, and any supporting documentation needed to demonstrate the claim’s medical necessity. Clean claims must meet payer-specific requirements and regulatory standards, and must be submitted within the payer’s required timeframe. Clean claims must also be free of errors, omissions, and inconsistencies, which can cause reimbursement delays or denials.
High rate of claims denials
Despite the importance of clean claims, nearly 15% of claims submitted to private payers for reimbursement are initially denied, with even higher rates for Medicare and Medicaid. These denials can delay patient care, reduce efficiency, and decrease patient satisfaction; they are also expensive, costing providers an average of $43.84 per denied claim to reprocess.
To avoid claim denials, experts at the Healthcare Financial Management Association (HFMA) recommend a 98% clean claims rate; however, achieving this rate requires accuracy at every step of the claims process.
The challenge of payer-provider collaboration
The value of claims data extends far beyond obtaining reimbursement. Claims data can be a valuable clinical resource, with numerous applications. Unfortunately, putting this data to best use has been challenging, as it requires payer-provider collaboration, which has traditionally been difficult to achieve.
However, value-based models create a shared goal for physicians and payers—improving patient outcomes—which encourages payer-provider collaboration. This, in turn, helps improve patient care.
The challenge of clinical data exchange
Another challenge in utilizing claims data lies in the traditional processes payers and providers have used to exchange clinical data. Manual, paper-based, and fax-driven exchanges remain common; at least 70% of providers still use fax to exchange medical information. However, these manual exchanges are time-consuming, error-prone, and can delay patient care.
Streamlining the exchange of claims data can help drive better patient care by enabling providers and patients to make more informed decisions more quickly—but only if the data exchanged is accurate, comprehensive, and, as a result, usable.
Clean claims: The foundation for value-based care
Clean claims have numerous applications, all of which help support the central tenets of value-based care: Improving patient outcomes while decreasing expenses.
1. Supplementing clinical data
Claims data can be used to supplement fragmented or incomplete clinical data, leading to better patient care.2
For every instance of patient care, a claim is filed, enabling payers to assemble detailed healthcare records for their members. As a result, payers often have the most complete and longitudinal view of patients’ health histories. By sharing this information with providers, they can give providers a clearer picture of a patient’s health situation. This enables faster, more informed decision-making for providers, resulting in improved patient care.
2. Improving care coordination
Sharing claims data also improves coordination of patient care, as it can give providers access to actionable information about patients’ other healthcare interactions. This, in turn, helps reduce test duplication, hospital admissions, and administrative overhead—all of which provide significant cost savings.
3. Identifying gaps in care
By applying risk analytics to claims and other clinical data, providers can gain greater insight into their patients’ healthcare needs. This process helps providers:
- Identify high-risk patients
- Identify and address gaps in preventive and chronic care
- Improve patient outcomes
Closing gaps in patient care is a key component of improving patient care and patient outcomes, but unless payers share their accumulated patient data, providers will not always be aware of patients’ existing care gaps. This process is only effective if payers have access to clean claims data; but by sharing this data, it results in both improved patient care and lowered healthcare costs.
4. Impact on value-based care
Value-based care requires providers to know the services and care a patient has already received to avoid unnecessary duplication; similarly, payers require data to monitor protocol adherence and identify ways to improve their health plan’s design.
The continuous, accurate exchange of claims data also supports quality metrics, such as the Healthcare Effectiveness Data and Information Set (HEDIS®) measures and Medicare Star ratings. Higher HEDIS scores and Star ratings help both payers and providers improve financial performance while simultaneously aligning with patient care goals.
Payerpath: A tool to facilitate clean claims
Veradigm understands the importance of clean claims data for payers, providers, and, most importantly, for delivering the best medical care to patients. That’s why the Veradigm Payerpath solution includes a clearinghouse function: To help clients obtain good, clean data the first time around.3
Veradigm Payerpath features a web-based claims management system that includes key functions such as claims management, remittance processing, and coding compliance tools. Its automated systems reduce human error, streamline workflows, and help ensure compliance. Payerpath’s Claims Management Solutions help practices to eliminate missing information, coding errors, and mistakes in data entry—any of which can lead to rejected or denied claims.
The result? Veradigm Payerpath helps practices achieve a first-pass clean claims rate greater than 98% across more than 3,100 payers.4
The power of clean claims
The value of clean claims goes far beyond gaining faster payments. Clean claims are the key to making value-based care successful. By ensuring the accuracy of claims data and leveraging technology to improve data exchange, providers and payers can:
- Reduce denials and the associated administrative costs
- Improve coordination of patient care and, as a result, improve patient outcomes
- Build stronger, more effective payer-provider partnerships toward improving patient care
The path forward to harnessing the value of clean claims doesn’t lie in treating claims as more paperwork. It lies in recognizing claims as a powerful data source, one that can enable better patient care and greater efficiency for clinicians.
Recognizing the value of clean claims data makes it a powerful tool for implementing value-based care. Veradigm Payerpath can help your practice make that a reality.
Contact Veradigm today to learn how Veradigm Payerpath can help your practice improve patient outcomes, operate with greater efficiency, and more.
References:
- Barnett W. The Role of Claims Data Management to Support Evidence-Based Healthcare (pre-publication draft). MedCity News (sponsored post).
- Barnett W. The Role of Claims Data Management to Support Evidence-Based Healthcare (pre-publication draft). MedCity News (sponsored post).
- Barnett W. The Role of Claims Data Management to Support Evidence-Based Healthcare (pre-publication draft). MedCity News (sponsored post).
- Veradigm Payerpath 2021. Data on file.