Claim scrubbing, also known as claims editing or claims validation, is a process in medical billing that involves reviewing and validating healthcare claims before they are submitted to insurance companies or third-party payers for reimbursement. The purpose of claim scrubbing is to identify and resolve errors, inaccuracies, or missing information in the claims to increase the likelihood of timely and accurate payment.
Here’s how claim scrubbing typically works:
- Electronic Claims Submission: In modern medical billing systems, claims are usually submitted electronically to insurance companies or clearinghouses. Claim scrubbing takes place at this electronic submission stage.
- Automated Validation: Claim scrubbing software or systems employ automated algorithms and pre-defined rules to evaluate claims for errors or discrepancies. These rules are based on industry standards, coding guidelines, payer requirements, and billing regulations.
- Error Identification: The claim scrubbing software analyzes the claim data and compares it against the predefined rules. It flags any issues or inconsistencies found in the claim, such as missing or incomplete information, incorrect coding, inappropriate modifiers, or other billing errors.
- Error Correction: Once the errors or issues are identified, the medical billing staff or software corrects the errors or prompts the user to make necessary corrections. This may involve updating or adding missing information, revising coding, or making other adjustments to ensure compliance and accuracy.
- Resubmission: After the necessary corrections have been made, the claim is resubmitted electronically to the insurance company or payer for processing. The claim scrubbing system may perform a final validation check to ensure that all errors have been resolved before resubmission.
The benefits of claim scrubbing include:
Improved Clean Claim Rate: Claim scrubbing helps reduce claim denials and rejections by identifying and resolving errors before submission. This increases the likelihood of clean claims that are more likely to be processed and paid promptly.
Increased Efficiency: By catching and fixing errors upfront, claim scrubbing reduces the need for manual follow-up, resubmission, and appeals, saving time and resources for medical billing staff.
Enhanced Revenue Cycle Management: Timely and accurate payment for services improves the revenue cycle of healthcare organizations, reducing delays and financial disruptions.
It’s important to note that claim scrubbing is not foolproof, and manual review and oversight by experienced billing professionals are still necessary. Claim scrubbing software can significantly assist in identifying common errors and inconsistencies, but it may not catch all potential issues. Human expertise and knowledge of specific payer requirements and regulations remain essential in ensuring accurate claims submission and maximizing reimbursement.