Roey Hine is Senior Vice President, Client Services & Operations, for Physicians Group Management.
Q: What is claims scrubbing?
Roey Hine: Claims scrubbing is a review of billing data and claims prior to submission to clearinghouses and insurance companies. That review is performed to ensure the claim is accurate, complete and compliant upon first submission so that the insurance company perceives it as a clean claim and has no excuse not to pay it upon its initial submission.
Q: Why is claims scrubbing important?
RH: There are two reasons in particular: 1) so the practice gets paid promptly from the insurance company; and 2) so the practice doesn't incur additional expenses in personnel time, claims clearing costs and delay of payment associated with handling a denial on the back end and needing to clean the claim up and resubmit it. We want to get paid on the initial claim and reduce expenses that are created by appeals, denials and resubmissions.
Q: How do you ensure a submitted claim is accurate?
RH: The rules we follow are the National Correct Coding Initiative (NCCI) Edits, developed by CMS. Scrubbing makes sure the data is complete, and the next step would be to determine whether the data passes certain tests: Are codes bundled or unbundled? Does the code require any modifiers? Does the diagnosis support the service being provided? In summary, does the claim meet the CCI edits?
Q: What approach does PGM take to scrubbing?
RH: At PGM, there are three levels of claims scrubbing designed to ensure claims submitted are as accurate, complete and compliant as possible. The first test takes place when billing data is imported or entered into our system manually. The system is designed to flag any mandated fields that are incomplete or missing.
The second level here at PGM involved our skilled account representatives. Every PGM account has a designated account representative who has knowledge of the practice and the practice specialty(s). This rep performs a visual review of all of the transactions to identify any transactions that may need refinement or correcting based on the representative's knowledge. For example, let's say a primary care practice submits an office visit and a procedure code done on a same day with separate diagnosis, and the office visit code should have a modifier -25 appended to it. If that's missing, the account rep, with knowledge of primary care coding rules, would add the modifier -25 prior to submitting the claim. The inclusion of modifier -25 would tell the insurance company that the office visit was separate from the procedure and should be payable separately.
After claims are processed at PGM, the third level of scrubbing occurs when the claims are run through a software edit through our clearinghouse. This checks to make sure the diagnosis supports the service and make sure the codes are not unbundled based on the CCI edits. That's done instantly after claims are run, and we are provided an opportunity, if necessary, to correct the claim before it's submitted to the insurance company.