One wrong digit can result in a denied claim. Learn about claim scrubbing and how it can lead to more revenue for your medical practice.
Claim processing speed is an oft-overlooked factor in the medical billing process. If claims process quickly, patients, providers, and insurers can rest easier knowing they’re not wasting their time or money.
That’s why claim scrubbing plays a vital role in the medical billing process. But claim scrubbing can be complex and confusing. Let’s dive into what claim scrubbing is, how it works and why it forms such an integral part of the medical billing process.
What Is Claim Scrubbing?
Claim scrubbing is a method of auditing claims before a provider files them with an insurance company.
This process consists of of screening your practice’s medical claims for flaws that might lead to payers denying the claim. Claim scrubbers, whether humans or computer systems, check the Current Procedural Terminology (CPT) codes on your claims.
This process is significant because, while describing your services with five-digit figures is handy, a single incorrect digit might result in a payer dismissing your claims.
Third-party tools offer claim scrubbing to reduce the amount of time spent processing claims. The primary focus of the service is to detect and eliminate any errors in billing codes, which in turn reduces the number of rejected claims.
The claim scrubbing process is crucial for any medical practice, and it can help you prevent denials in the future.
Essential Elements of Claim Scrubbing
The U.S. healthcare industry involves more than patient care; it’s an incredibly complex and multi-faceted set of processes. Most medical professionals want to focus on patient care, not the complexities of claim filing. Unfortunately, a less-than-perfect claim process can lead to billing and revenue cycle issues down the line.
Fortunately, claim scrubbing offers a viable solution to medical billing process issues faced by both medical professionals and healthcare providers. And although claim scrubbing can be tricky to understand, we can simplify the topic by breaking it down into three essential elements.
Medical Claims
The entire medical billing process begins with a clinician providing their services to a patient. To receive payment for treating a patient, a doctor must send a claim to the insurance company. However, this process does not mean the insurance company will automatically approve the claim.
Many people assume that having medical insurance means that their treatment is fully covered. However, insurance companies scrutinize claims and often reject or deny them for a variety of reasons (incorrect information, no prior authorization, out-of-network provider, etc.). These claim denials and rejections can cause revenue cycle problems for providers and payment headaches for patients.
CPT Codes
The medical billing process is extensive, and filing a claim means providing as much information as possible for the insurance company to assess. Because of this, the medical billing community has resorted to using codes to streamline the process.
Think of codes like a key on a map. Rather than explaining each case in excruciating detail, medical professionals instead use a standardized set of numbers that denote specific forms of treatment, diagnoses, etc.
While the medical community has broadly accepted this system, it is not without flaws and imperfections. The main downside of using the Current Procedural Terminology (CPT) codes is the wide margin for error. All it takes for an insurance company to deny a claim is a single wrong number.
Additionally, CPT codes change regularly to comply with the Health Insurance Portability and Accountability Act (HIPAA). This can be difficult and time-consuming to keep track of, further increasing the margin for error
Fortunately, effective claim scrubbing will help identify any errors before you send a claim.
Service Providers
Though many medical professionals manually check every claim for errors and inconsistencies, automated options significantly speed up the process.
Claim scrubbing companies use software that automatically checks each claim. These companies act as a kind of mediator between medical practices and insurance companies, making the entire process more manageable for everyone involved.
They are experts in spotting red flags and finding opportunities for your practice. They also save time for healthcare businesses, practices and providers, allowing them to focus on their patients.
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What Does the Claim Scrubbing Process Entail?
Claims processing is a complex system with more than 20 checkpoints.
If a claim clears all of these hurdles, the insurance company authorizes it and processes any insurance benefits. If it does not, the insurance company refuses or returns the claim for further information.
Following a claim through the system is the simplest method to learn claims processing. As an example, let’s see what occurs after a patient leaves the doctor’s office:
- Submission is the first step. The doctor’s billing department submits a claim to a clearinghouse within no more than 48 hours after the appointment, where it is routed to data entry to be recorded electronically.
- Conduct a first evaluation. The claim is processed by an algorithm to ensure that there are no duplicate charges, mistakes, unreadable text, or erroneous data.
- Determine your eligibility. The patient’s name and policy number are checked against the clinic’s database to ensure that he is a member with a current insurance plan.
- Establish a network. The doctor and clinic location are checked against a database to verify if they are part of the network.
- Repricing. The algorithm examines the services billed for by the doctor and applies negotiated rates.
- Benefits determination. The patient’s insurance benefits are compared to the services they received via the system.
- Examine medical need. The claim is reviewed by the system to ensure that the things the doctor invoiced are medically required, in accordance with industry best practices, and safe for the patient.
- Conduct a risk assessment. Depending on the types of services performed, individual line-item expenditures, and overall charges on the bill, the system classifies the claim as low-risk or high-risk for insurance fraud.
- Make a payment. The doctor gets paid the amount the insurance covers based on agreed rates in accordance with the patient’s benefits.
- Benefits Explanation. The company provides an explanation of the benefits to illustrate how much the doctor billed, how much he got paid, and how much the patient may owe as an out-of-pocket payment.
- Bill. If payment is needed, the patient will get a bill from the doctor’s office that should correspond to the amount and services mentioned in his explanation of benefits.
Benefits of Claim Scrubbing
Claim scrubbing offers many benefits for medical providers and insurance companies. These benefits include:
- Preventing rejected claims: Once a clinician provides services, they will need to file a claim to be paid. Claims can be convoluted and tricky, with a wide margin for error. A claim scrubbing service can eliminate errors before the claim is ever filed.
- Improving cash flow: Ironing out any claim errors reduces the time it takes for an insurer to accept the claim.
- Reducing time spent rectifying claims: Claims are tricky business, and using a claim scrubber will ensure that you spend as little time as possible reviewing your claims for errors.
- Improving payer-patient relations: Filing a claim can waste valuable time and money for everyone involved, from patient to provider. An effective claim scrubbing service will save on these valuable commodities, ensuring that everyone involved has the best experience possible.
Additionally, claim scrubbing ensures that each claim is compliant with HIPAA, as frequent updates to the law can be challenging to track and remember.
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Automated vs. Manual Claim Scrubbing
The claim scrubbing process is sometimes a manual task. Unfortunately, this time-consuming process takes resources away from more important duties like patient care. And regardless of experience, manual claim checks will always have some margin for error.
Fortunately, automated electronic claim scrubbing services exist, reducing errors to almost 0%. These services also save time for billing teams by streamlining the entire process.
Through the power of AI technology, claim scrubbing software can update itself in real-time (in accordance with new CPT codes). It can also scan documents at a faster rate than the average human.
AI-Powered Claim Scrubbing
Claim scrubbing has emerged as one of the medical world’s most enduring practices. But it has come a long way since the days of manually checking every claim for errors. Now, thanks to automated claim scrubbing tools, the medical billing process is more straightforward and streamlined.
Gentem’s AI-powered medical billing and RCM platform drastically improves the quality of your claims. That means you’ll spend less time scrubbing claims and more time providing quality care to your patients. Book a demo to see what Gentem can do for your practice.
