Accidentally changing a single digit can lead to days’ worth of energy and resource waste. It is crucial that a claim remains accurate and complete.
As per a Kaiser Family Foundation (KFF) study of Affordable Care Act (ACA) plans,17% of claims were denied, while one insurer was found to deny 49% of claims.
Mundane errors often pave the way for a claim to be denied. To prevent this, claim scrubbing comes to the rescue.
What is Claim Scrubbing in Medical Billing?
Claim scrubbing is a critical quality control measure that thoroughly analyzes each claim to identify and rectify any possible error or inaccuracy before it is submitted to the insurance company.
The monitoring includes:
- Cross-checking the codes used.
- Ensuring that compliance with regulatory requirements is maintained.
- Holding up the medical standards.
The greater good of this practice is that it helps streamline the overall revenue cycle management as claim denials are minimized, and reimbursements are acquired faster.
Before, claim scrubbing was done manually, where employees used to sit and review each document to ensure accuracy. However, now, sophisticated software systems called claim scrubbers are employed, enabling automated claims checks.
Benefits of Scrubbing Claims
Faster reimbursements:
When claims are denied, the process of correcting and resubmitting them is not just taxing on energy and resources, but it also wastes time. The delayed reimbursements slow down revenue collection, which negatively affects a provider’s finances.
However, scrubbing claims minimizes the potential for denials and enables speedy payments. Revenue is, thus, boosted.
Steady cash flow
Slower reimbursements due to claim denials lead to a restricted cash flow. Moreover, reworking the claims itself leads to a loss in revenue.
According to research conducted by Premier, medical providers spent almost $20 billion reworking denials in 2022. Moreover, as per a study by the Medical Group Management Association (MGMA), 50% to 65% of denied claims are never reworked, which means the cost and resources invested in creating the initial claims are wasted, and there is no reimbursement.
Scrubbing claims prevents this and allows the cash flow to be steady and consistent.
Improved client relations
No patient would appreciate receiving a claim for a much higher payment than what is due in reality. Such discrepancies dent the provider’s relationship with the patient as the patient would no longer trust the provider. Unhappy patients eventually lead to a bad reputation, thereby reducing client inflow. Chiropractic medical billing companies, for instance, rely heavily on accurate claim scrubbing to maintain trust and ensure seamless billing processes, especially for specialized services. Scrubbing claims guarantees the patients that their medical bills are in good hands, in compliance with regulations, and they are not being over or undercharged.
Increased productivity
Reworking an already submitted claim manually can be very demotivating for employees. An automated system of claim scrubbing would make claim submission a faster and much easier process.
Moreover, medical practitioners would not need to spend their time on administrative tasks and could focus on more important things, like providing quality healthcare to their patients.
Better compliance
Scrubbing a claim includes verifying its compliance with governmental regulations. This leads to the providers being updated with any changes that might occur in the rules. The employees are better informed, and thus, compliance is enhanced.
Challenges in Medical Claims Scrubbing
Compliance
Ensuring that a claim abides by valid healthcare regulations is a major component of scrubbing a claim. Regulations are subjected to frequent changes; thus, it may be difficult to keep up with the recent developments regularly. Constant monitoring is needed to make sure the claim is compliant.
Time
If done manually, claim scrubbing can be a very time-consuming task. One has to scrutinize all details to ensure there is no inaccuracy. Claim scrubbing takes time; if it is rushed, a claim becomes susceptible to the risk of denials.
Different payer requirements
Every patient’s insurance plan has different criteria that should be adhered to for claim submission. Managing these variations and maintaining each payer’s guidelines can be complicated.
These challenges often arise when there is a lack of an automated process and things are handled manually. A club scrubbing software might be expensive, especially with the training required to operate it, but it proves to be an economical choice in the long run.
Claims Scrubbing Process
Initial submission
Within 48 hours of a patient’s visit to the hospital, the patient’s information, billing details, and billing codes are verified and entered into the billing system. A claim is generated.
Initial evaluation and eligibility check
This process is automated, and an algorithm is run through the claim to ensure the absence of any discrepancy (like a duplicate charge, a wrong number, unreadable text, etc.). The patient’s details, policy number, and insurance plans are also double-checked.
Code verification
Each service is tallied against its procedure code to ensure the correct codes have been generated. Any upcoding or downcoding issue is rectified.
National coding standards (like ICD-10, CPT, and HCPCS codes) are maintained.
Repricing should be done if negotiated rates are applied to services.
Medical necessity and compliance check
The services billed are checked to verify if they are a medical necessity, safe, and in accordance with the payer guidelines and industry standards.
Risk Assessment
The claim is classified by the system as low-risk or high-risk for insurance fraud, depending on individual line-item expenditures and the overall billing amount.
It is necessary to make sure that the agreed rates are in accordance with the patient’s benefits.
Final review and submission
A final review is conducted to ensure that there is no discrepancy in the claim to minimize the risk of denials.
After review, the claim is submitted to the insurance company to be processed and reimbursed.
Follow up
It is essential to track submitted claims to enhance revenue cycle management. If a denial occurs, then it should be managed immediately.
Bottomline
Claim scrubbing is, without a doubt, a very necessary part of medical billing. One extra run-through over the claim can save energy, money, resources, and time.
Manually scrubbing the claim is unsuitable for most practices, especially with the busy client load, which is why MediBill is here to help.
Our expert billers and coders carry out vigorous claim scrubbing to ensure that your claims are always free from errors and do not risk denial.
It is finally time to say goodbye to denied claims.