Clean-Claim Rate Lift for Multi-Specialty Clinic

Context

• Multi-specialty provider group on a single EMR; charge entry performed by clinic staff with inconsistent edit handling.
• High volume of payer-specific rejections (COB, eligibility, modifiers) and recurring clearinghouse edits.
• No shared defect taxonomy; recovery from rejections was ad hoc and slow.

Approach

• Claim-scrub & charge-entry pods with payer edit playbooks embedded in the workbench.
• Defect taxonomy by payer and claim type (eligibility, COB, modifiers, bundling, LCD/NCD).
• AQL QA sampling with reviewer calibration and exemplars tied to policy language.
• Rejection SWAT lane with 24–48h recovery SLA and root-cause tagging.
• Dashboards for clean-claim rate (CCR), first-pass yield (FPY), rejection mix, and recovery TAT.

Measured Results

• Clean-claim rate +11.8 pts in 6 weeks.
• First-pass yield +9.1 pts, sustained with weekly drift checks.
• Rejection recovery TAT ≤ 48h on 92% of items.
• Edit recurrence −26% via targeted coaching and SOP updates.

Lessons Learned

• Edit playbooks reduce variance more than generic ‘best practices’.
• Recovery lanes must have clocks and owners to prevent re-aging.
• Tie QA comments to payer policy text to avoid subjective debates.
• Track edit recurrence; the goal is prevention, not heroics.