The success of any Revenue Cycle Management process depends upon collections. Every technology and process in the revenue cycle, is focused on increasing revenue. Amongst the many factors that can measure and reflect the health of the AR, one is the First Pass Resolution Rate (FPRR).

FPRR is the percentage of claims that are paid in the wake of being presented in a solitary time. This measurement lets you know how powerful your Revenue Cycle Management is. The FPRR is calculated as the number of claims paid on first / initial submission, divided by the total number of claims submitted (in a specific time period).

There is an important concept that revenue cycle leaders need to understand with regards to the FPRR. When billing companies and other Outsourcing Partners say that they have a Clean Claim Rate of over 90%, it is often assumed that 90% of claims are being paid. Unfortunately, Clean Claim Rate and FPRR are two completely different measures of your Revenue cycle.

Clean Claim rate reflects the percentage of claims accepted by the clearing house, without any rejection. Even though a minimum of 95% of Clean Claim Rate is to be maintained, that would not assure a good FPRR. Hence it is important to take hand-in-hand measures that would improve your Clean Claim Rate and also your FPRR.

Measures to Improve your Clean Claim Rate & FPRR

1. Patient Demographics: Incorrect patient data is often the common reason for claim rejections at the clearing house. Even a small miss-match in spelling or DOB will automatically result in rejections. Verifying correct patient information prior to claim submission will increase both your Clean Claim Rate and FPRR, by a huge extent.

2. Eligibility verification: Did you know that Eligibility issues are the primary cause that affects your FPRR and thereby having a major impact on your Revenue Cycle Management? As per the Change Healthcare 2020 Denial Index, denials due to eligibility constitute a whopping 26.6%; resulting it being the top cause of denial. Eligibility verification should be done as soon as the appointment is scheduled at the practice, so as to ensure a smooth claim process.

3. Timely Filing Limit:  Untimely filing is one error that cannot be rectified later on, unless you have genuine proof of timely filing. It results in the claim being written off; thereby resulting in a loss of revenue and decreases your FPRR. Some payers have 30 days while some have up to 2 years. It is important to keep a check on the TFL, so as to prevent any rejections and denials.

4. Coding Accuracy: We all know the importance of coding accuracy. Coding is one major denial that affects FPRR. Irrespective of specialty, there are coding guidelines that are updated often by different payers. What might be the correct way to code for one payer, may be incorrect with another. Following these guidelines can prove to be one easy way to increase your Claim Rate and FPRR.

5. Documentation: As a back-end process, accurate documentation with regards to patient medical history and case history always helps in clarifying any information required by payers on time, hereby ensuring faster resolution.

The above points constitute some unique and specific ways to ensure a better Clean Claim and FPRR.

Rule Engine Optimization

Rule Engine is a software designed to auto-apply some specific rules through algorithms. We can ensure maximum Clean Claim Rate and FPRR with this. We can apply the Rule Engine across any scope of Revenue Cycle Management.

Rule Engines are set up using both payer edits and specific client edits (aka guidelines). Before a claim is transmitted, the claim has to satisfy both these edits and go through a scrubbing process before final transmission. These edits consist of coding guidelines, patient demo formatting guidelines and other specialty specific guidelines. In short, all the previously mentioned measures to improve Clean Claim Rate and FPRR can be resolved by setting up a Rule Engine platform. With these edits in place, any claim that does not follow these guidelines will automatically be pulled out from the Que of transmission.

For example, in the case of a Medicare claim, as per the new policy number format, it should be a mix of alpha numerical. If the policy number is in the older format, i.e. SSN with the alpha at the end, the Rule Engine automatically identifies this and pops up the claim as an error.

Another example is, when submitting a claim to BCBS, the DOS should be less than 180 days prior to the date of transmission. If the claim has a longer DOS, the Rule Engine identifies this and marks the claim for Untimely filing.

At Quintessence, we have an inbuilt Rule Engine platform across all the scopes and as part of our proprietary tools, including the computer-assisted coding platform Codessence. Our Rule Engine platform can be developed for any specialty across data entry, coding and billing scopes. The best part is, we can integrate our Rule Engine platform with your billing software, thereby only allowing only Clean Claims to enter your system.

Maintaining a FPRR of at least 85-90% is a reflection of good Revenue cycle Management. If your FPRR is underwhelming, do contact Quintessence for a free evaluation.