The claim scrubbing process entails examining your practice’s medical claims for defects that could result in payers rejecting the claim. Human or computer systems claim scrubbers, review your claims for Current Procedural Terminology (CPT) codes.
In other words, claims processing is a complex workflow with over 20 checkpoints that each claim must pass through before it is approved. The insurance company approves and processes any insurance payments if a claim clears all of these hurdles. If it does not, it is denied or returned for additional information.
While describing your services with five-digit figures is convenient, a single incorrect digit could result in a payer rejecting your claims.
Most people never have to deal with medical claims unless there is a hiccup during processing. However, because the system is so complex, claims occasionally appear in consumers’ lives. Even when everything is running smoothly, claims processing impacts two things everyone is concerned about: how much (and how quickly) their doctor is paid and the amount they owe their doctor. As a result, comprehending claims at a high level is advantageous.
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Claims Necessitate A Large Amount Of Coded Information.
The amount of information on any given claim is mind-boggling. Claims must include personal information about the patient, individual physicians, the medical staff, the healthcare provider, and all tests performed, procedures, diagnoses, and treatments. They also include information about the insurer.
To standardize claim processing, insurers employ a set of codes. Coding all the information accurately is critical if the claim is to be paid on time.
Unfortunately, the process’s complexity leaves a large margin for error. ICD-9 contains over 13,000 diagnosis codes and over 3,000 procedure codes. One thousand more HCPCS and CPT codes have been added. HIPAA compliance is also required for claims. To add to the difficulty, codes are regularly updated, and there are an infinite number of possible combinations.
Any errors will lead to the claim being rejected. It can be aggravating when a simple error, such as incorrectly entering the patient’s sex, results in a lengthy delay while the claim is corrected and resubmitted.
Alternatives to Hiring Claim Scrubbers
The services provided by claim scrubbing companies are not free. As a result, many healthcare providers are looking for alternatives. The best alternative to claim scrubbing is to use a high-quality electronic health record system that is constantly updated. The best EHR systems provide comprehensive billing assistance. Users do not need to remember codes because the system will provide them automatically. When entering bills, users select the raw information from built-in databases, and the system generates the correct code.
This greatly reduces the possibility of an error when entering bill details. To maintain accuracy, it still requires care and attention, but nowhere near the same amount of concentration as manual billing.
Some EHR systems, such as those offered by Integrity Support, include clearinghouse fees as a perk. This allows healthcare providers to benefit from claim scrubbing services without additional costs.
Claim Scrubbing’s Key Elements
The healthcare industry in the United States is more than just patient care; it is an incredibly complex and multifaceted set of processes. Most medical professionals prefer to concentrate on patient care rather than the complexities of claim filing. Unfortunately, a flawed claim process can lead to later billing and revenue cycle issues.
Fortunately, claims scrubbing provides a viable solution to medical professionals and healthcare providers’ medical billing process issues. And while claims scrubbing can be difficult to grasp, we can simplify the topic by breaking it down into three key components.
- Medical Insurance Claims
The medical billing process starts when a clinician provides services to a patient. Then, a doctor must submit a claim to the insurance company to be paid for treating a patient. This procedure, however, does not guarantee that the insurance company will automatically approve the claim.
Many people believe that having medical insurance entitles them to full coverage for their treatment. But on the other hand, insurance companies scrutinize claims and frequently deny or reject them for various reasons (out-of-network provider, no prior authorization, incorrect information). These claim denials and rejections can disrupt providers’ revenue cycles and cause patient payment issues.
- CPT Codes
The medical billing process is lengthy, and filing a claim necessitates providing as much information as possible for the insurance company to evaluate. As a result, the medical billing community has turned to codes to help streamline the process.
Consider codes to be a key on a map. Rather than going into excruciating detail about each case, medical professionals use a standardized set of numbers to denote specific types of treatment, diagnoses, and so on.
While the medical community has widely embraced this system, it is not without shortcomings and weaknesses. The primary disadvantage of using Current Procedural Terminology (CPT) codes is the large margin for error. A single incorrect number is all it takes for an insurance company to deny a claim.
Furthermore, CPT codes are updated regularly to comply with the Health Insurance Portability and Accountability Act (HIPAA). However, keeping track of this can be difficult and time-consuming, increasing the margin for error. Fortunately, effective claim scrubbing will assist you in identifying any errors prior to submitting a claim.
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- Service/Infrastructure Providers
Although many medical professionals check each claim for errors and inconsistencies by hand, automated options significantly speed up the process. For example, claim scrubbing companies use software that checks each claim automatically. These businesses act as a sort of go-between for medical practices and insurance companies, making the entire process easier for everyone involved.
They are experts at identifying red flags and opportunities for your practice. They also save time for healthcare organizations, practices, and providers, allowing them to devote more time to their patients.
The Output Of The Claim Scrubbing Process
If a claim passes all these tests, the insurance company will authorize it and process any insurance benefits. If it does not, the insurance provider rejects the claim or returns it for more personal data.
The simplest way to learn claims processing is to follow a claim through a computer program. Consider what happens after a patient leaves the doctor’s office:
Submission: Within 48 hours of the appointment, a claim is submitted to a clearinghouse by the doctor’s finance dept, which is channeled to data entry and recorded electronically.
Conduct a preliminary assessment: An algorithm checks the claim to ensure no duplicate charges, errors, unreadable text, or incorrect data.
Check your eligibility: The clinic’s database is searched using the patient’s name and policy number to ensure that he is a current insurance plan member.
Create a network: To see if the doctor and clinic are part of the network, they are checked against a database.
Repricing: The algorithm examines the doctor’s services and applies negotiated rates. It includes the fees’ the insurance company agreed to pay the doctor and the facility in their contract.
Determination of benefits: The patient’s insurance benefits is weighed against the services provided by the system. It determines whether the Insurance company covers each service and how much it will pay based on his plan details.
Examine your medical requirements: The system reviews the claim to ensure that the items invoiced by the doctor are medically necessary, in accordance with industry best practices, and safe for the patient. This step ensures that the patient does not pay for services he does not require.
Perform a risk assessment: The system classifies the claim as low-risk or high-risk for insurance fraud based on the types of services provided, individual line-item expenditures, and overall charges on the bill. Therefore, the patient’s claim appears to be low-risk.
Pay your bill: The doctor is paid the amount that the insurance covers, based on agreed-upon rates based on the patient’s benefits.
Benefits Explanation: The company explains the benefits so that the patient understands the amount the doctor charged, how much he was paid, and how much the patient may be required to pay out of pocket. The doctor examines his explanation of benefits to ensure that all of the information is correct and corresponds to the services he received.
Bill. If payment is required, the patient will receive a bill from the doctor’s office for the amount and services listed in his explanation of benefits. The payment should correspond to the amount and services listed on the doctor’s explanation of benefits( EOB).
Improving The Claims Process For Better Output
It may appear to be a miracle that claims get through all these steps without encountering any barriers. But unfortunately, getting claims from point A to point B is difficult.
The three primary objectives are timeliness (did we process claims faster), accuracy (did we pay the correct price for the correct services), and cost efficiency (did we process claims automatically). If any of these objectives are not met, it can cause problems for all parties.
By improving the team’s implementation strategy, using data to discover and evolve, computerized claims hold, and develop advanced matching algorithms for member and doctor’s information. With early detection of risky charges, the new system can reduce errors, pay claims more quickly, and increase the number of claims that move through the system without requiring a person to look at them.
Because claim reimbursement is so complicated, it’s understandable that many health insurers depend on outsourced solutions. While you can continue making gradual improvements with the supplier, the only way to make a remarkable change is to work with the providers directly.
It can take up to 9 months to transition from an external setup with operational and technological components to an internal setup—to replicate the existing infrastructure.
The ultimate goal is to process claims efficiently so that doctors spend less time looking for payments for the care they have already provided and to reduce errors so that consumers never have to deal with denied claims or paying for services they never received. Hopefully, the claims processing system of the future will be so seamless that we won’t even notice it’s there.