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During the rigorous training physicians undergo to learn their craft, very little education is received on how to deal with submitting claims to insurance companies.  It’s unfortunately a necessary evil, as surgeons who contract with insurance companies rely on that reimbursement as the lifeblood for practice survival.

Receiving payment from insurance payers involves submitting claims after providing treatment.  Whether it’s in an office setting, emergency room, or an operating room, filing a claim involves supplying the appropriate procedure and diagnosis codes along with any appropriate modifiers pertaining to the treatment performed.  However, simply filing a claim does not assure that it will in fact be paid.

The policies of insurance companies for accepting or rejecting claims change often. A claim that got paid last month may be currently denied without notice depending on carrier specific modifications.  This results in a large batch of denied claims for surgeons performing many of the same procedures.  Not only is it confusing for a practice to attempt following up on these adjustments, it can result in lengthy days in accounts receivables along with rollercoaster collection periods.

Is there a secret weapon orthopedic surgeons can use to assist with streamlining claims to maximize acceptance?  That’s where claim “scrubbing” enters the picture.  The term “scrubbing” refers to an intricate cleaning of a claim prior to submission.  Over the past 10 years, automated claims editing has been developed which helps to validate that a claim is appropriate and accurate for submission.

There are two components in scrubbing claims.  As the most common error for denied claims is data entry errors, the patient demographic data is reviewed for the most common mistakes.  For instance, keying in an incorrect procedure code that is age specific would make the claim invalid, and the scrubber flags those types of errors for correction prior to submission. This is the easy part of the automation.

The complicated portion of scrubbing involves a thorough review of the codes and modifiers to ensure complicity with carrier specific guidelines. This is commonly referred to as the “rules engine.”  In some fashion, every data element of the claim is analyzed. If a physician submits a claim for a hysterectomy and the scrubber sees a male gender it will obviously be flagged.  The scrubber verifies that a procedure performed is associated with a diagnosis code that justifies the medical necessity of that procedure along with variables such as gender, age, date and place of service and any required modifiers.  The complexity of scrubbing should not be underestimated.  By the time one multiplies the total number of Medicare local and national coverage determinations, along with data from the Correct Coding Initiative (CCI), ICD-9 codes, and modifiers the potential numbers of editable combinations surpasses ten million. Advanced claim scrubbers, though, can review about ten claims per second.

By including national and local coverage determinations from all of the Medicare geographical regions in every state along with data from the Correct Coding Initiative (CCI), approximately 35% of existing CPT® codes are represented as a baseline in claims editing programs.  There is no Medicare medical necessity guidelines for the remaining 65% of codes, therefore claim scrubber software companies hire clinicians and nurses who work full time evaluating up to the minute medical necessity data posted by insurance carriers around the country on their website as mandated by law. In addition, procedure codes are matched with all feasible diagnosis codes that are believed to be clinically defensible for claim acceptance. As one might expect, this is a costly endeavor so most claim scrubbing software companies license this portion from the few companies performing the research.

So how good are existing claim scrubbers?  There’s a wide range available, either as a standalone product or integrated with practice management software. Often the billing company utilized will incorporate a scrubber. The best ones will routinely achieve over 95% claim acceptance on the first pass. Practices who were previously performing manual edits typically find that after instituting the technology the scrubber flags over 30% of claims. This means about 30% potential claim denial prior to scrubbing, which drags out the revenue cycle. By having the scrubber flagging problem claims, changes can then be made instantly prior to submission, rather than waiting weeks for a denial.  As a result, the practice will see more reimbursement and receive those funds faster. There will also be less back-end work secondary to denied claims.

Can relying on an experienced coder achieve the same acceptance rate?  In all likelihood, No.  As mentioned, scrubbers check demographic information along with the codes. Also, if a payer changes a filing guideline on its claim form or a medical necessity requirement, a certified coder would probably not be aware of it in a timely fashion.  If a surgeon is contracted with a large amount of carriers, the chances of being subjected to rejected claims increases dramatically without a way of continually monitoring these myriad and often complex requirements.

Embracing an advanced claim scrubber, whether directly or indirectly, will allow one’s practice to effectively combat the convoluted world of insurance claim rules and regulations.  Practices that incorporate claim scrubbing rarely move away from the process.  When the bottom line receives a significant boost along with peace of mind from knowing the latest technology is in their back pocket, why would they?

Dr. David Greene is a residency and fellowship trained orthopaedic surgeon. He serves as the Director of Medical Relations for SilverTree Health, a full service medical insurance reimbursement company. Contact information: dgreene@silvertreehealth.com or (877) 652-8733

Originial Article on Codapedia.com

Author: 
David Greene, MD