Healthcare providers have the primary responsibility to care for patients and improve their lives. Dealing with claim processing and handling payer-related issues can be managed in-house, but it is not an ideal situation, given the layers of intricacies involved in the process.
Thus, we curated this comprehensive guide on claim scrubbing in medical billing. In this guide, we will discuss the benefits of the scrubbing process, terms you should be familiar with, and how the process works.
So, without further ado, let’s get started!
What is Claim Scrubbing in Medical Billing?
Claim scrubbing is a process that systematically analyzes claims to identify and correct inconsistencies, inaccuracies, and errors before submitting them to insurance companies.
Simply put, it is a quality control measure, ensuring all medical claims comply with regulatory requirements, coding standards, and insurance payer’s guidelines.
Common Errors Caught By Claim Scrubber
During the claim scrubbing process, you may catch one or more of the following errors:
- Discrepancies in procedure and diagnosis codes
- Error in date of service provided
- Incorrect member ID
- Inappropriate modifier usage
- Lack of supporting documentation
- Downcoding or upcoding
- Missing admission date on an inpatient claim
- Non-compliance with the National Correct Coding Initiative (NCCI)
Benefits of Scrubbing Claims
Are you still unsure, how the claim scrubbing workflow can help you overcome your medical billing challenges? If yes, you must not skip this section!
Error-Free Claims
Claim scrubbing helps healthcare practices create accurate claims, leading to fewer denials, and streamlining your payment collections and cash flow.
Faster Reimbursements
When you receive a denial, it slows down your payment cycle, straining your overall revenue cycle. However, with accurate claim submission, you can enhance the claim first-pass rate, resulting in faster reimbursements and a steady cash flow.
Enhanced Payer-Provider Relationship
Errors or missing information can trigger denials, which ultimately strain the payer-provider relationship. Besides, various insurance companies have different claim submission guidelines.
However, by employing a robust claim scrubbing workflow, you not only minimize the occurrence of denials but also adhere to the payer’s requirements, improving the payer-provider relationship and strengthening your network.
Improved Patient-Provider Relationship
Claim denials can also upset patients. How? When the insurance payer refuses to reimburse the rendered care services, the patient becomes responsible for paying the amount out-of-pocket. If this issue persists, your practice will lose credibility, and patient flow will reduce significantly, making it challenging to meet ends.
Contrarily, scrubbing enables you to overcome this issue by lowering the denial rate, keeping patients satisfied, and improving the patient-provider relationship.
Avoid Spending Time Reworking on Claims
Reworking claims is a tricky business that requires time, effort, and money. Utilizing a claim scrubbing process enables you to avoid spending time reworking and resubmitting claims, enhancing your practice’s revenue cycle.
Claim Scrubbing Terms You Should Know
Discussed below are some common claim scrubbing terms you should be familiar with:
Superbill
It is an itemized list outlining the provided services with the date of service. It is used as a roadmap while creating a medical claim.
Coding Errors
If a biller or coder enters wrong information on a claim form, it is called a coding error, which may lead to claim denial or payment delays.
Claim Form
It is a document justifying why a payer should reimburse a healthcare provider or a facility.
Claim Editing
It involves a claims review to identify errors and rectify issues on a claim form before submitting it to the insurance company for faster reimbursements.
Charge Review
It involves reviewing service or procedure rates against standard charges set by Medicare, Medicaid, and other private payers.
Claims Scrubbing Process
Claim processing is complex and includes over twenty checkpoints. Claim scrubbing in medical billing helps you pass all these hurdles for successfully authorizing reimbursements against the rendered care services.
If during the claim scrubbing process, any check fails to address and rectify the issue, the payer will deny the claim, asking for supporting documentation. For simplicity, let’s take a look into what happens after a patient encounter:
- The billing team submits the claim within 48 hours of the patient leaving the facility and records the details electronically.
- In the second step, conduct a first evaluation using an algorithm to avoid errors, inaccuracies, or duplicate charges.
- The patient’s insurance eligibility is determined. The billing team cross-checks the insurance policy number and name against the clinic’s database.
- The healthcare facility’s location and healthcare provider details are verified to ensure they are a part of the network.
- The algorithm checks the billed procedures or services and applies negotiated rates.
- At this stage, you should determine the patient’s benefits against the provided services via the system.
- Next comes a review of provided services and claims for medical necessity and appropriateness.
- A risk assessment is performed based on service type, billed charges, and individual line items to determine whether the claim is high-risk or low-risk.
- The physician gets the rightful reimbursements for the rendered services based on the negotiated rates from the payer.
- The insurance company offers a summary – an Explanation of Benefits (EOB), entailing how much you billed, what you received, and what amount the patient owes to the provider.
- If the patient has financial responsibility, he will get a bill from the provider’s office listing the services and charges mentioned in the explanation of benefits.
Now that you understand what happens after the patient leaves the facility and how claim processing works, it is time to understand the two types of claim scrubbers.
The first claim scrubber audits complete information, while the second checks for accuracy. Regardless of what type you are using, they will both look for errors and discrepancies after the billing report is ready to submit. If it finds any issue, it will flag it so that a billing specialist or coder may fix it.
Difference Between a Charge Scrubber and a Claim Scrubber
A charge scrubber audits the billing reports before the billing specialist compiles them. Contrarily, a claim scrubber audits the billing reports before submitting them to the payer.
Both offer the same benefits, i.e., helping you steer clear of errors to reduce the likelihood of denials and speed up reimbursements. The only difference is whether the audit is done before generating billing reports or after generating billing reports.
Difference Between Automated and Manual Claim Scrubber
You can complete the claim scrubbing process using a manual or automated scrubbing tool.
First, understand how manual claim scrubbing works! Humans are responsible for handling it. They could be your staff or contractors. You can do it in-house if you can afford to hire a certified professional coder (CPC) trained in over 3,000 codes, HIPAA regulations, and medical jargon.
Otherwise, we recommend outsourcing the process to an expert with proper credentials and a willingness to stay current on changing industry standards to ensure error-free claim processing.
The automated claim scrubbing software automatically scrubs claims and speeds up the process. These software are more efficient because they can spot errors that humans may miss, resulting in a reduced denial rate and boosting your healthcare organization’s credibility.
Bottom Line
In medical billing, claim scrubbing is a quality check that identifies inaccuracies and discrepancies in the generated claims and supporting documents. It prevents inconveniences like denials and write-offs.
Some common terms related to this process, include superbill, claim form, claim editing coding errors, and charge review. The scrubbing process consists of several steps, like electronically recording the details, using algorithms to spot errors, verifying the entered information, and performing a risk assessment.
Understanding the terminology and differences between a claim scrubber and a charge scrubber or automated vs manual claim scrubbing will help you make the process more efficient.
We hope that this guide will help you understand the benefits of scrubbing and you will implement it to streamline your claim processing workflow. However, if you find it challenging to do it in-house or don’t have the required funds, consider outsourcing to a professional medical billing company, like MediBill MD. At MediBill MD, we have a team of CPCs and billing specialists who can help you out!
