Leveraging the Power of Medical Claim Edits: Expediting Payments for Hospitals and Health Systems


Claim Edits

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July 13, 2023

As hospitals and health systems strive to optimize revenue cycle management, the role of edits in streamlining claims processing and expediting payments has become increasingly crucial. Medical claim edits serve multiple purposes, from preventing denials to ensuring compliance with regulations and enhancing revenue capture and standardization. In this blog post, we will explore the significance of edits and the various types that can be employed to maximize efficiency and financial outcomes.

Benefits of Medical Claim Edits

One of the primary goals of edits is to prevent denials. By proactively addressing deficiencies in claims before submission, organizations can significantly reduce the risk of rejections and the subsequent need for costly appeals and resubmissions. Clean claims minimize administrative burdens and facilitate faster payment, enabling hospitals and health systems to improve cash flow and decrease days in accounts receivable.

Medical claim edits also play a crucial role in addressing deficiencies in other systems. With the ever-evolving landscape of healthcare regulations and standards, edits ensure compliance by validating claims against requirements such as ICD-10, HCPCS, CPT-4, HIPPS codes, and ANSI Standard Implementation Guide Edits. Compliance with these guidelines helps mitigate the risk of audits, penalties, and revenue loss.

Moreover, edits contribute to increased revenue capture by identifying and correcting errors or omissions that may result in under-coding or missed reimbursement opportunities. By standardizing and ensuring consistency in claim content and format, edits optimize the accuracy and completeness of submissions, leading to improved revenue generation for hospitals and health systems.

In an era where healthcare organizations face operational challenges such as staffing changes and increased time in accounts receivable, edits offer a lifeline. According to a recent MGMA Stat poll, 76 percent of medical practices reported making operational changes in response to staffing challenges. Automating claim corrections through edits frees valuable staff time, allowing for greater focus on critical tasks and reducing the burden of manual error correction. The result is increased operational efficiency and improved financial performance.

Let’s delve into the different types of edits that can be deployed to optimize claims processing.


Types of Medical Claim Edits

  1. Translator Edits/Bridge Routines: These edits address issues with the data content and format of the input file sent to billing. They can automatically correct certain errors and are usually specific to a provider organization, similar to Provider Specific Edits.
  2. Generic Edits: These edits encompass elements required on every claim, regardless of payer or provider. Examples include patient names and facility names, which must adhere to the standard (e.g., 837I or 837P). Generic edits are not generally payer-specific and can be related to Medicare and/or compliance requirements.
  3. All Payer Edits: This category includes a wide range of edits based on ANSI Standard Implementation Guides, covering structure, compliance, and code validity across different code sets such as ICD-10, HCPCS, CPT-4, and HIPPS codes. Additionally, payer-specific companion guides, conjunction edits, Not Otherwise Classified (NOC) edits, age/gender edits, National Uniform Claim Committee (NUCC) 1500 guide edits, and place of service edits fall under this umbrella.
  4. Medicare Specific Edits: Medicare imposes specific requirements requiring unique edits to ensure compliance. These edits encompass aspects such as medical necessity, local coverage determinations by state (LCDS), CMS national coverage determinations (NCDS), CMS transmittals, appropriateness criteria for advanced diagnostic imaging, durable medical equipment (DME) medical necessity, add-on code edits, preventive care warning messages, and PDGM & PDPM (HIPPS) edits.
  5. Multiple Payer Edits:  Edits that can be requested to be turned on for any payer.
  6. Medically Unlikely Edits (MUE): MUE edits help identify and prevent excessive or medically unlikely units of service for specific procedures or services. For example, MUE edits ensure procedures that are gender and/or age specific are not billed on a claim for the incorrect gender/age.
  7. National Correct Coding Initiative (NCCI) Edits: NCCI edits focus on preventing inappropriate coding combinations that may result in an overpayment. These edits help ensure compliance with coding guidelines and prevent unbundling of services. They include global period edits, specialty-specific rule edits, fee schedule edits, and payer-specific CCI edits.
  8. Duplicate Claim Edits: Duplicate claim edits identify and prevent the submission of duplicate claims for the same services rendered to the same patient. These edits help eliminate unnecessary claims processing and reduce the potential for overpayment.
  9. Provider Carrier Edits: Provider carrier edits are based on payer and regulatory requirements that may not necessarily affect all provider types. These edits can be specific to a contract between the payer and a given provider or group of providers, or they can be requested for a particular payer. They ensure compliance with specific payer policies and guidelines.

SSI Pre-Billing Eligibility Edits

In addition to the aforementioned edits, the utilization of Pre-Billing Eligibility (PBE) edits can offer a final eligibility check at the time of billing, protecting against rejections, return-to-provider (RTP), and denials related to eligibility issues. PBE, which can be used in conjunction with any eligibility solution already in place, involves the creation of eligibility requests based on claim data, which are then matched with eligibility responses from payers. Discrepancies in coverage and benefits are identified as edits on claims, helping to prevent denials.

More Claim Edit Control Options

To provide even more control and customization, edit controls offer various options to manage edits effectively. Bypass edits automatically bypass specific edits based on configurable criteria, streamlining the claims process. Additionally, edit configuration options can be set at the service level, edit level, or coordination of benefits (COB) edit level, allowing for tailored control over edits.

To further enhance efficiency, EHR-embedded validation services provide programmatic access to a vast array of edits, allowing electronic health record (EHR) systems to leverage the power and precision of edits within their workflows. This integration enables real-time validation of claims, reducing the reliance on traditional back-end claims scrubbers and promoting cleaner claims at the point of discharge, resulting in faster payment.

Recent advancements include the 5.x Validation Engine, which moves away from full claim validation to partial claim validation based on claim changes. This technology stack allows for optimizations, such as concurrent charge processing, claim size considerations, and partial claim re-validation using edit culling based on claim change deltas. These optimizations significantly improve the speed and efficiency of the validation process.

What’s Next

Looking ahead, the future holds exciting possibilities for claim edits. Users will eventually be able to create their own translator edits and bridge routines, empowering organizations to tailor edits to their specific needs. Another feature to look forward to is called the Replace Job, which will enable corrections for recurring edits, using “find & replace” type functionality. There will also be options that allow users with certain access and privileges to be able to turn edits on and off.

In conclusion, the strategic utilization of edits is essential for hospitals and health systems to expedite payments, reduce denials, ensure compliance, increase revenue capture, and promote standardization. By leveraging the power of various edit types provided mostly by healthcare clearinghouses, organizations can streamline claims processing, improve cash flow, and optimize overall financial performance.

Not All Edits Are Created Equal 

SSI’s comprehensive edit suite is one of the most advanced in the industry. Our robust edits encompass payer-related, industry/regulatory-related, and provider edits tailored specifically for payers. Time and time again, new clients are amazed by the number of new edits and errors we catch on their claims. These discrepancies are often missed by their previous vendors, highlighting the depth and breadth of our edit suite. With an impressive track record spanning 25 years, our dedicated team, boasting an average tenure of 18 years, has painstakingly built and perfected our edit suite.

Here are more reasons why our edits stand out:

  • A newly deployed edits digest is delivered weekly.
  • SSI covers more areas of the revenue cycle and more scenarios than our competitors.
  • We test and test some more to ensure the edits are accurate.
  • SSI is better equipped to handle complex scenarios.

To learn more, schedule a demo or contact us.

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