Claim scrubbers and claim creation: What They Are and How to Get Them Right?

Claims Scrubbing and Creation: What They Are and How to Get Them Right?

Table of Contents

Introduction

Claim scrubbers play a crucial role in the medical billing process as they are designed to meticulously scan claims for errors before they are submitted to payers. These claim scrubbing automated software programs are responsible for ensuring that all information on the claim is accurate and complete, including patient demographics, diagnosis codes, and CPT codes. In the event that errors are detected, a highly skilled medical biller or coder will step in to manually rectify the claim, ensuring that it is error-free and ready for submission. This process helps to reduce claim denials and rejections, ultimately leading to faster reimbursement for healthcare providers and a smoother experience for patients. In this article we will discuss what is claim scrubbing and the role of claim scrubbers in medical billing and coding.

What is meant by claim scrubbing?

Claim scrubbing refers to the procedure of thoroughly reviewing medical insurance claims to identify errors that can lead to the rejection of claims. This process involves the use of claim scrubbers, which can either be individuals or computer programs that help in ensuring the accuracy of the Current Procedural Terminology (CPT) codes. Precision in these codes is crucial because they simplify the representation of services by using five-digit numbers. Even a single incorrect digit can result in claim denials. Claim scrubbing is the process of identifying and rectifying coding errors present in medical claims before submitting to insurance companies. Claim scrubbers conduct reviews and validate the information contained in medical claims before they are sent to payers (insurers).

How does claim scrubbing work?

I would be glad to hold a comprehensive conversation with you regarding the intricacies of claim scrubbing.

Provider Bills Submission

When patients receive medical treatment or services, healthcare providers are responsible for submitting bills to ensure they are properly compensated for their work. These bills detail the specific medical services provided, along with any associated costs and fees. It is important for healthcare providers to accurately document and submit these bills to ensure timely payment and to avoid any potential billing errors or discrepancies.

Medical Coding

The role of medical coders is to accurately and efficiently convert medical bills into standardized reports. This requires a deep understanding of medical terminology, coding systems, and billing procedures. Medical coders play a critical role in the healthcare industry by ensuring that records are properly coded and billed, which in turn helps to ensure accurate reimbursement for healthcare services and treatments. It is a highly specialized and important profession that requires attention to detail, accuracy, and a commitment to upholding the highest standards of ethics and professionalism.

Medical Billing

When it comes to submitting claims to insurance providers, medical billers typically rely on two main forms: the CMS-1500 and the UB-04. These forms are critical for ensuring that healthcare facilities receive timely and accurate payments for the services they provide to patients. While the CMS-1500 form is used primarily for physician services, the UB-04 is designed specifically for hospital services. Both forms require careful attention to detail, as even minor errors or omissions can lead to delayed or denied claims. As such, it’s essential that medical billers have a thorough understanding of these forms and the requirements for submitting them accurately.

Claim Volume and Accuracy

Depending on the size of the organization, medical billers handle numerous bills daily. Due to the high volume, it is challenging for them to review each report for accuracy thoroughly. Mistakes in the claim can lead to claim denials or claim delays that cause cash flow issues and increase operational costs.

Claim scrubbers are typically part of third-party medical billing services. Their role is to examine medical bills in order to ensure their accuracy. Claim scrubbers are helpful across various healthcare facilities, including hospitals, dental practices, and outpatient centers. Some scrubbers ensure that forms are properly filled out, while others perform more detailed audits to ensure overall accuracy. The process of claim scrubbers can be carried out manually or through computerized systems. However, the majority of claim checks are now automated for efficiency.

Who provides claim scrubbing services?

Claim scrubbing services are predominantly offered by third party medical billing companies like Ensure MBS. For instance, athenahealth, a medical software firm, utilizes automated rule engines to detect errors that might trigger claim rejections. Another example is Ensure MBS, a medical billing company, which takes an additional step by utilizing the preferred scrubbing tool of its clearinghouse partner. In both instances, the claim scrubbing technology employed by these providers surpasses human capabilities in swiftly and accurately identifying errors. For the above mentioned reasons, when come upon the term “claim scrubbers”, it refers to automated services provided by third party entities. Although individuals can perform claim scrubbing, you will soon comprehend that there needs to be more justification for your medical staff to undertake this task.

Why is claim scrubbing important?

The process of claim scrubbing holds significant importance in the medical billing industry for a multitude of reasons. It involves the thorough examination and review of medical claims to ensure accuracy, completeness, and compliance with all relevant regulations and guidelines. Claim scrubbing helps prevent claim denials, reduce errors, and ensure timely reimbursement for healthcare providers. Overall, it plays a critical role in maintaining the integrity and efficiency of the medical billing process.

More Accurate Claims and Fewer Denials

Claim scrubbing leads to more accurate claims. When your claims are accurate, the chances of facing claim denials decrease. This means it becomes easier to encounter fewer hurdles in receiving the necessary funds from insurance companies.

Faster Payments

Denied claims result in payment delays. With approved claims, it is possible to receive payments. With claim scrubbers, the chances of submitting accurate claims increase, which lead to timely payments. This improved cash flow helps to meet the financial requirements of the business.

Time Savings

Manually reviewing claims for errors not only increases the risk of mistakes but also consumes a considerable amount of time. However, Claim scrubbers eliminate this manual process. As an alternative, a computer program efficiently and quickly identifies errors. This saves time, allowing your staff to focus on interacting with patients.

Enhanced Relationships with Payers

The majority of people have health insurance, making payers the primary revenue source for healthcare organizations. by Consistently submitting incorrect claims to payers, which often have specific requirements, people harm their relationship with insurance providers. Claim scrubbers reduce invalid claims, leading to improved payer relationships.

Better Patient Relationships

Frequent claim denials not only affect payers but also disturb patients. Receiving startling bills for services, they believed were covered can lead to patient dissatisfaction. Claim scrubbers mitigate this issue by reducing claim denials and ensuring that patients receive the expected coverage. Meeting patient expectations contributes to better patient retention and a more expedited claim management process.

Enhancing Claim Submission Accuracy: Best Practices to Follow

Regular Training Sessions

Consistently provide training to staff members for better handling of claim submissions. These practice sessions should encompass up-to-date coding updates, billing guidelines, payer requirements, and any procedural changes. Keeping the team well-informed can significantly reduce errors.

Automated Claim Scrubbing Implementation

Leverage automated claim scrubbing tools to spot errors and inconsistencies within claims before they’re submitted. This proactive approach reduces the chances of claim rejection and strengthens accuracy.

Comprehensive Patient Information Verification

Ensure that patient details, including demographics and insurance information, are accurate. Verifying this data during registration and updating it as needed can surely prevent inaccuracies.

Embrace Standardized Coding

Adhering to standardized coding practices guarantees accurate and consistent claim submissions. Using the proper codes for diagnoses and procedures while adhering to coding guidelines is of utmost importance.

Scheduled Audits

Regular audits can serve as a valuable tool for identifying areas for improvement in the claim submission process. This involves reviewing denied claims, identifying common errors, and implementing corrective measures.

Claim Status Monitoring

Keeping tabs on claim status post-submission is vital. Regularly track claim rejections, denials, and appeals to ensure they are handled accurately and efficiently.

Five (5) claim scrubbing software tools

Optum

Optum streamlines the claim scrubbing process with its efficient and quick auditing capabilities. The system automates the claims review to identify potential errors, missing information, and questionable coding. A support team is available to assist with editing standard, specialty, and custom rules.

Claim Editing Software

With years of experience, Claim Editing Software offers more standard and built-in edits compared to its competitors. The tool analyzes claims and provides detailed reports that can explain edits in user-friendly language. Its exclusive database doubles the coverage of CPT codes by pointing out all potential ICD-9, CPT code combinations. The medical content database is regularly updated for accurate results by using this claim scrubbing software.

ClaimWizard

ClaimWizard Pro features a software wizard setup assistant that helps the users in selecting accurate codes and eliminating coding lapses. Its cross-walk feature automatically matches ICD codes with the suitable CPT/HCPCS codes. Built-in edits ensure that claims adhere to nationally accepted coding guidelines and standards.

Code-A-Note

Code-A-Note claim scrubbing software utilizes natural language processing to choose and validate suitable codes that help in enhancing coder accuracy and efficiency. It compiles its extensive data from important sources such as the U.S. National Library of Medicine, Centers for Disease Control and Prevention, Centers for Medicare & Medicaid Services, National Center for Health Statistics, and American Medical Association.

Billing Bridge

Billing Bridge is a mobile app designed for medical managers. it allows users to handle billing tasks conveniently from their smartphones. It provides data analysis for financial purposes and offers real-time updates and alerts on claim payments. This particular code-scrubbing software tool emphasizes the return on investment (ROI) of the bill-scrubbing process.

Comparing Manual and Automated Claim Scrubbers in Medical Coding

The complexities of medical coding can often lead to coding errors. Let’s dig into some of the challenges that coders encounter.

Understanding ICD-9 Codes

Medical coders must possess a comprehensive understanding of the 13,000 diagnosis codes and 3,000 procedure codes found in the ICD-9 (International Classification of Diseases, Ninth Revision), which is an official code system in the U.S.

HCPCS and CPT Code Knowledge

Coders need to be experienced in the numerous HCPCS (Healthcare Common Procedure Coding System) and CPT (Current Procedural Terminology) codes.

Familiarity with Medical Terminology

Coders must have a solid grasp of medical terminology and framework to comprehend the content they are working with.

Procedure and Code Proficiency

Coders must also be proficient in the most commonly used procedures and codes while staying updated on coding changes.

Accurate Code Permutations

Proper code permutations are essential to accurately reflect a patient’s visit as documented in surgical records, office notes, laboratory findings, or pathology reports.

Detailed Visit Data

Coders’ reports must include patient particulars, healthcare provider information, individual physician details, medical staff involvement, and comprehensive accounts of diagnoses, procedures, treatments, and conducted tests.

Maintaining HIPAA Compliance

It is imperative to ensure that all documents strictly adhere to the regulations set forth by HIPAA. This means that all sensitive information contained within these documents must be handled with the utmost care and confidentiality. Any breach of these regulations could result in significant legal and financial consequences, not to mention the negative impact it could have on the parties involved. Therefore, it is crucial to take every precaution necessary to ensure the security and privacy of all sensitive data.

Given the complex nature of coding, many healthcare practices choose healthcare claims management software to handle their claims rather than manual processing. This software can be installed as a single product or can also be bundled within comprehensive medical software, revenue cycle management software, or comprehensive medical practice management software.

Automated solutions offer a faster and more accurate approach as compared to manual handling by front-office staff. Automation ensures around-the-clock availability, significantly improving efficiency. Ultimately, the adoption of automated solutions translates to saved time and reduced costs for healthcare organizations, leading to a more engaged workforce and an enhanced patient experience.

Conclusion

By and large, it can be concluded that the processes of claim scrubbing and creation are essential to the financial health and efficiency of healthcare practices. The accuracy of medical claims submitted to insurance companies determines the reimbursement, revenue flow, and overall sustainability of healthcare operations. Claim scrubbers serves as a vital standard to ensure that these claims are free of errors, compliant with regulations, and aligned with payer requirements.

Through review of all claims by using automated tools, errors are identified and rectified before submission. This proactive approach not just minimizes claim rejections and denials but also enhances the overall revenue cycle management. Moreover, accurate claims submission contributes to stronger relationships with both payers and patients. It helps in fostering trust and reliability in the healthcare organization’s operations.

The adoption of best practices for claim scrubbers are; regular training, standardized coding, thorough patient information verification, and automated claim scrubbing, significantly improves the accuracy and efficiency of claim submission. These practices do not just reduce errors but also streamline the billing process, which leads to faster payments and increased financial stability.

As the healthcare industry continues to evolve, the significance of accurate claims creation and claim scrubbing is also getting important. Healthcare organizations that prioritize these processes are better positioned to deal with the complexities of medical billing. These medical billing companies also have better opportunities to cultivate positive relationships with payers and patients and ultimately provide quality patient care. By protecting these standards, healthcare practices can ensure their financial viability, operational excellence, and continued growth in a competitive healthcare environment.

Frequently asked questions (FAQs)

What is claim scrubbing in the medical billing process?

Claim scrubbing is aimed at identifying and rectifying coding errors in medical claims before they are submitted to insurance companies. This proactive process helps prevent claim denials and delays, ensuring accurate and timely reimbursements.

How do claim scrubbers differ from manual review processes?

Claim scrubbers can be either automated systems or manually conducted reviews. While manual reviews are time-consuming and prone to human errors. Automated claim scrubbers use advanced algorithms to quickly and accurately detect coding mistakes and inconsistencies.

Can claim scrubbing tools be customized to suit different healthcare facilities?

Yes, claim scrubbing tools can often be customized to meet the specific needs of various healthcare facilities. These customized tools can be used in hospitals, dental practices, and outpatient centres. Customization ensure that the tool effectively addresses the unique requirements of each setting.

What are the key benefits of utilizing automated claim scrubbing services?

Automated claim scrubbing services offer several benefits. Prime benefits include; improved accuracy, reduced claim denials, faster payments, time savings, and enhanced relationships with both payers and patients. These advantages contribute to better financial stability and operational efficiency.

How can healthcare organizations improve their coding accuracy and reduce errors?

To enhance coding accuracy, healthcare organizations should implement best practices such as regular staff training, embracing standardized coding guidelines, verifying patient information thoroughly, and utilizing automated claim scrubbing tools.

What is the role of standardized coding practices in claim submission accuracy?

Standardized coding practices ensure that medical claims are submitted using consistent and accurate codes for procedures. Adhering to these practices helps in preventing errors. It also reduces claim denials and improves overall claim submission accuracy.

How does automated claim scrubbing contribute to better relationships with payers and patients?

Automated claim scrubbing reduces the chances of submitting incorrect claims to payers. This lead to improved relationships with insurance providers. Additionally, accurate claims submissions result in fewer surprises for patients and enhance patient satisfaction and retention.


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