Integrating Claim Edits to Increase Cash Flow

Claim scrubbing is the process of reviewing claims for errors prior to submitting to the assigned payors. This is done to ensure a clean claim is submitted, minimizing denials and delay in payments. 

Setting up edits within your Practice Management system will help identify errors that could be causing claims to be denied. This review takes place after the claims are entered but before they are submitted to the payor for processing. By finding and correcting the errors prior to submission, you can decrease denials and improve the timeliness of claim payments. In the end, claim scrubbing can save your staff time correcting errors that could have been prevented – and save you the costs associated with sending a claim multiple times.  

Most Practice Management systems have generic default edits built in. However, additional edits can be written to tailor the process to your practice and specialty. Setting up Claim Edits presents numerous benefits, including:

• Quicker correction of errors
• Timely payments from payors
• Reduction of denied claims, keeping your accounts receivable % within appropriate MGMA benchmarks
• Ability to identify trends that can be used for education within the practice

• Unbundling – Setting up global periods and NCCI edits to flag CPT codes that will deny as bundled
• Place of Service – If a professional claim has an incorrect place of service (POS), it will be denied
• Duplicate Denials – Multiple E/M services that are performed on a single date by the same provider must be combined and submitted as a single service
• Payor Restricted Codes – If a payor does not allow for certain CPT codes to be billed
• Eligibility – A wide range of potential edits including missing ID number, effective date invalid, and missing DOB
• Diagnosis-to-Procedure Appropriateness (Denial Code CO-11) – This is one of the most prevalent denial codes, where the claim is denied for the procedure code not matching the medical service offered. Referring to the Local Coverage Determinations (LCD) for a list of procedure codes, relating to the services addressed in the LCD, and the diagnoses for which a service is/is not considered medically reasonable and necessary will eliminate these denials.

Claim scrubbing and edits help ensure more accurate claim submissions and expedited payments, resulting in increased cash flow and decreased time spent working denials. If you are experiencing significant claim denials – or would like support optimizing your process – MMG’s revenue cycle experts can help. Contact us to learn more.