Redefining Clean Claims: A Technology-Driven Reimbursement Framework

Every physician practice wants a high clean claim rate. But as Bronson Cox pointed out in “Redefining Clean Claims: A Technology-Driven Reimbursement Framework,” part of Medical Economics’ September 2025 Practice Academy, the industry’s favorite metric rarely tells the whole story.

Most clean claim calculations stop at clearinghouse acceptance — not payment. That means a practice could boast a 97% clean claim rate while still facing a 40% denial rate on the back end. Cox argued that this disconnect leaves practices chasing the wrong goal: acceptance instead of actual reimbursement.

Instead, he urged practices to track first-pass payment rates — how often a claim is paid in full the first time it’s submitted without human rework. Even small improvements, he said, can make a meaningful financial impact given the volume of claims most groups process daily.

Cox also stressed the importance of rethinking workflows. Too many practices waste time “rebilling” the same claims over and over without changes — a cycle he likened to making spaghetti and hoping it sticks. With the right tools, billing teams can spot denial patterns, capture payer-specific rules, and prevent claims from getting lost in the black box of adjudication.

Clean claim rates aren’t enough. Practices should measure what matters — payment outcomes — and use technology to reduce rework, shorten days in A/R and build a more resilient revenue cycle.

About the presenter

Bronson Cox, chief operating officer at Encoda

Bronson Cox is the Chief Operating Officer and co-founder of Encoda, where he oversees product development and operations. With 25+ years in health care technology — including 18 years specializing in ANSI X12 EDI for medical claims and payments — he brings deep expertise across practice-management systems, software product development and program leadership.

For the past 14 years, Bronson has served on the ANSI X12 835 committee, advancing standards for payment posting and denial management. Earlier, he held executive roles at WebMD Practice Services and led Technology Services at Lee Data Systems (The Medical Manager, now part of Greenway Health).