April showers and May flowers mean one thing: spring! Unfortunately, it’s also the time of the year many individuals – and businesses – conduct spring cleaning.

We’re not only talking cleaning windows and vacuuming curtains though. For hospitals, it means working to approve the upcoming fiscal year’s operating budgets based on both actual results and year-end projections. These projections will most likely be challenging due to the negative financial effects of the COVID-19 pandemic. Many hospitals and healthcare providers were operating on thin margins before the pandemic, with only enough cash and patient receivables to cover 3 to 4 months of operations. 

Providing exceptional care is the mission of the healthcare community, and that centers on revenue. Investing in specialized talent who can actively guide your team toward peak financial performance activates that mission.

Reporting 101

For about 1/3 of hospitals, the end of the fiscal year falls only a few months before they’re required to submit cost reports to fiscal intermediaries as part of the Hospital Inpatient Quality Reporting (Hospital IQR) Program. Through the program, the calendar year 2020 quality measure data hospitals report and submit to the Centers for Medicare & Medicaid Services (CMS). That reporting affects their future Medicare payment between October 1, 2021 and September 30, 2022 (fiscal/payment year 2022).

doctor and data

After receiving the data, CMS assesses its accuracy through a validation process to verify that it meets the program’s requirements. Although the agency employs multiple measures from a variety of data sources to CMS uses a variety of measures from various data sources to determine the quality of care that patients receive, it calculates the measure rates based only on data provided to them by hospitals on their claims.

The Hospital IQR Program’s claims-based measures reflect patient outcomes and healthcare costs and utilize Medicare enrollment data and Part A and Part B claims data. Each hospital provides its data through claims it sends to Medicare to obtain reimbursement for the care provided to the patient.

To ensure their claims are as clean as possible, coding professionals step in to help minimize risk and earn sustainable results. The knowledge and expertise of these experts aid in reducing coding errors, a concern that resulted in $28.91 billion in improper payments in 2019.

Calculating the clean claim rate

A higher clean claim rate, recommended as a top KPI to track to maintain a strong revenue cycle, means a provider gets reimbursed faster and often on the first submission. This rate or percentage is calculated by dividing the number of claims paid on first submission by the total number of claims accepted into the claims processing tool for billing.

The industry standard for clean claim rate is 75% – 85%, with a lower number indicating a provider is ineffectively processing its claims. Expert coding professionals benefit hospitals by affecting a lower denial rate and reducing the number of days of claims in A/R.

medical coding skills

Our highly qualified consultants are primed to help achieve sustainable results in quality, compliance, and reimbursement. Partner with us today so our experts can begin identifying processes and policy changes to establish a robust and complete revenue cycle your organization. 

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