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Claims scrubbing in medical billing is the process of electronically reviewing and validating healthcare claims before they are submitted to insurance payers for reimbursement. It involves running the claims through automated software or systems that identify and flag errors, inconsistencies, or missing information that could potentially lead to claim denials or delays in payment. Any discrepancies found during scrubbing are flagged for correction, enabling providers to address issues proactively and resubmit clean claims. Implementing claim scrubbing as a part of the medical billing process is a proactive approach to RCM.

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In this blog, we will delve into the importance of claims scrubbing in medical billing and ways to implement it in medical claims processing effectively.

Claims Scrubbing in Medical Billing Example

When the billing department of a hospital is preparing to submit a claim for surgery, they use claim scrubbing software to ensure its accuracy.

The software reviews the claim to detect issues if any. Suppose it spots that the ICD-10 code for the patient's diagnosis is incorrect, and one of the CPT codes for a procedure performed during the surgery is missing. It flags these two flaws to the team. The team then corrects the issues. With these corrections, the claim is accurate and ready to be submitted.

When the corrected claim is submitted, it is processed quickly and approved by the insurance company. This efficient process ensures that the practice receives timely payment for the services provided, reducing administrative workload and improving cash flow.

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Common Claim Scrubbing Terms You Should Know: Superbills: Superbills are the itemized lists of services provided to the patient; they’re the primary source for creating claims.
CMS-1500 and UB-04: CMS-1500 and UB-04 are the most common medical forms for compiling patient case history and billing claims.
Claim-editing tools: Claim-editing tools, or claim-scrubbing software, are integrated with electronic health records or practice management systems to ensure that claims are billed at the actual contracted amount, coded accurately, and processed as quickly as possible.
Charge review rules engines: Charge review rules engines review, correct, and apply millions of coding rules to submitted claims to ensure billing accuracy.

The Significance of Claims Scrubbing in Medical Billing

Claims scrubbing is important because it offers the following benefits:

1. Error Prevention

Claims scrubbing in medical billing helps identify and rectify errors, such as missing or incorrect patient information, incorrect coding, or incomplete documentation, before claims are submitted. By catching these errors early on, providers can reduce the chances of claim denials and delays, ultimately increasing revenue cycle productivity through effective medical billing services.

2. Increased Efficiency

Scrubbing claims before submission ensures that they meet the specific requirements of different payers. This helps minimize rework and resubmissions and saves time and effort for both the healthcare provider and the insurance payer. It also streamlines the billing process and accelerates reimbursement timelines.

3. Compliance with Payer Rules

Different insurance payers have specific rules and guidelines that must be followed when submitting claims. Claims scrubbing in medical billing ensures that the claims adhere to these rules, preventing potential non-compliance issues. This includes checking for correct coding, modifier usage, and medical necessity documentation.

4. Reduced Claim Denials

By identifying and addressing errors or inconsistencies, claims scrubbing significantly reduces the risk of claim denials. It helps ensure that claims are accurate, complete, and meet the specific requirements of insurance payers. This leads to a higher rate of clean claims, increasing the likelihood of timely and accurate reimbursement.

5. Financial Optimization

Effective claims scrubbing in medical billing results in higher first-pass acceptance rates, reducing the need for costly and time-consuming appeals or rework. It maximizes revenue by minimizing denials and payment delays, improving cash flow and overall financial performance for healthcare providers.

6. Regulatory Compliance

Claims scrubbing also plays a key role in ensuring compliance with regulatory requirements, including HIPAA, by verifying that patient information and documentation are appropriately handled and protected.

What are the functions of claim scrubbing software?
Claim scrubbing software automates the review of medical claims to identify errors, missing data, and non-compliance issues. It ensures accurate and clean claims before submission, reducing denials, improving reimbursement rates, and streamlining revenue cycle management for healthcare providers.

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Case Study
Invensis assisted a US physical therapy provider in improving medical billing revenue by 35%. Read this case study to know how.

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Significance of Claim Scrubbing in Medical Billing — Figure 1 : Benefits of Scrubbing Your Claims

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Roles of a Scrubber in Medical Billing

Here's an overview of the key functions of scrubbers:

Error Detection: Identification of common mistakes, such as incorrect or missing diagnosis (ICD-10) and procedure (CPT) codes, patient information errors, and non-compliance with insurance guidelines.
Compliance Checking: Adherence of claims to current healthcare regulations and payer-specific requirements to reduce claim denial risks.
Data Validation: Validation and completion of all necessary fields ensure the claim is ready for processing.
Efficiency Improvement: Automated error-checking process, speed up the billing cycle for administrative workload reduction.

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Common Errors Caught by Claims Scrubbing

Below are some of the most common errors detected during the claims scrubbing process:

Incorrect Patient Information
Errors such as misspelled names, incorrect birth dates, or invalid insurance policy numbers can cause claims to be rejected. Claims scrubbing tools verify patient data to ensure accuracy.
Invalid or Incorrect Medical Codes
Mistakes in CPT, ICD-10, or HCPCS codes, such as using outdated codes or mismatching diagnosis and procedure codes, are flagged during claims scrubbing, ensuring compliance with coding standards.
Missing or Incomplete Information
Missing fields, such as provider NPI numbers, dates of service, or authorization details, are identified by claims scrubbing tools, ensuring all required data is present.
Duplicate Claims
Claims scrubbing detects duplicate submissions that could lead to claim denials or delays, helping maintain a smooth billing process.
Insurance Coverage Errors
Claims scrubbing identifies issues like claims submitted to the wrong insurer, policies that are no longer active, or coverage limitations that may lead to denials.
Mismatched Modifier Usage
Incorrect or inappropriate use of modifiers can lead to claim rejections. Claims scrubbing ensures modifiers are used correctly in alignment with payer-specific rules.
Non-Compliant Claims
Claims that fail to adhere to payer-specific or regulatory guidelines, such as missing required attachments or invalid claim formats, are flagged for correction.

How to Improve Claims Scrubbing Process?

Healthcare providers can enhance the claim scrubbing process in several ways:

1. Implement Robust Software

Investing in advanced claims scrubbing software helps healthcare providers streamline the process and improve accuracy. These tools utilize automated algorithms to detect errors and inconsistencies, ensuring claims are clean before submission.

2. Conduct Ongoing Staff Training

Regular training sessions for billing and coding staff help practices stay updated with the latest coding guidelines and payer requirements. Well-trained staff are more equipped to identify potential errors and resolve issues during the claim scrubbing process.

3. Perform Internal Audits

Conducting internal audits of the claim scrubbing in the medical billing process allows providers to identify patterns of errors, areas of improvement, and training needs. This feedback loop helps refine the process and ensure ongoing accuracy and compliance.

4. Collaborate with Payers

Building strong relationships with insurance payers can help healthcare providers gain insights into payer-specific requirements. Also, regular communication and feedback exchanges can minimize claim rejections and denials.

Figure 2 : Best Ways to Improve Claim Scrubbing Process

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What is the Clean Claim Rate in Medical Billing?

A clean claim rate in medical billing is the percentage of claims submitted to insurance companies without errors or deficiencies. A clean claim contains all required information, including accurate patient details, diagnosis codes (ICD-10), procedure codes (CPT), and any necessary supporting documentation. A clean claim rate indicates the effectiveness of claim processing, reduces administrative costs, and ensures faster reimbursement cycles.

Conclusion

Claim processing in the healthcare industry is becoming increasingly complex due to various factors. Evolving regulatory requirements, changing payer policies, and advancements in medical technology contribute to the growing complexity. New codes and guidelines, such as ICD-10, require meticulous documentation and coding accuracy.

Even payers implement stricter scrutiny, which leads to increased claim denials and appeals. Additionally, the rise in value-based care models and complex reimbursement structures adds further intricacy to the process. To navigate this complexity, healthcare providers must stay updated, invest in robust technology, and consider delegating the task to experienced professionals who can handle the intricacies of claims processing efficiently.

Invensis has over 24 years of experience in providing claims scrubbing support services to healthcare providers. We provide access to specialized expertise, scalable resources, and improved efficiency. It allows healthcare providers to focus on core patient care while ensuring that their claim scrubbing in the medical billing process is handled by professionals with in-depth knowledge of payer requirements and industry best practices. Get in touch with us now to overcome the difficulties of claim processing and streamline your RCM process.

Frequently Asked Questions

1. What type of code do claim scrubbers analyze?

Claim scrubbers analyze medical codes, including ICD (International Classification of Diseases) codes for diagnoses, CPT (Current Procedural Terminology) codes for procedures, and HCPCS (Healthcare Common Procedure Coding System) codes for supplies and services. This ensures accuracy and compliance before submitting claims to insurers.

2. What is a scrubber, and what value does it have in the claims process?

A scrubber is a software tool that reviews medical claims for errors before submission to insurers. It ensures codes are accurate and compliant with regulations, reducing claim denials and rejections. This streamlines the claims process and improves reimbursement efficiency for healthcare providers.

3. What is a clean claim in medical billing?

A clean claim in medical billing is a correctly completed claim form submitted to an insurer without errors or omissions. It includes accurate patient information, diagnosis codes, and procedure codes, ensuring timely processing and payment without the need for additional information or corrections.

4. What are scrubbing errors?

Scrubbing errors are mistakes identified by claim scrubber software during the review of medical claims. These errors include incorrect or missing codes, mismatched patient information, or non-compliance with insurance guidelines. Correcting these errors before submission helps practices prevent claim denials and delays.

Janet Scott

Janet is a seasoned professional in the medical billing industry, with extensive knowledge and expertise that enhances her writing. With years of experience, she adeptly handles the complexities of healthcare reimbursement processes. Janet's proficiency spans various medical specialties, consistently delivering valuable insights and implementing effective revenue cycle solutions. She excels in coding compliance, claims submission, and denial management. As a prominent writer in the medical billing space, Janet provides concise and actionable advice, empowering healthcare providers to optimize their financial performance with confidence.