Claim Scrubbing

The automated process of reviewing healthcare claims for errors, inconsistencies, and compliance issues before they are submitted to payers.

Claim scrubbing is the automated quality check that catches errors in your claims before they reach the payer. A claim scrubber reviews each claim against a set of rules and flags problems that would likely result in a denial or delay. What does a scrubber check? Invalid or expired CPT and ICD-10 codes, diagnosis-procedure code mismatches, National Correct Coding Initiative (NCCI) edits that flag bundling issues, duplicate claims, missing or invalid modifiers, invalid place of service codes, patient eligibility status, timely filing compliance, and payer-specific rules. Claim scrubbing happens at two levels. Your practice management system or EHR usually has built-in scrubbing rules. Then your clearinghouse applies a second layer of scrubbing before transmitting the claim to the payer. Together, these two checkpoints catch the majority of errors that would otherwise result in denials. The return on investment for claim scrubbing is immediate and measurable. Practices with good scrubbing typically have clean claim rates above 95%. Without scrubbing, clean claim rates can drop to 70-80%, which means 20-30% of your claims need rework. At $25 to $50 per reworked claim, the cost adds up fast. Not all scrubbers are equal. Basic scrubbers check for format errors and invalid codes. Advanced scrubbers check NCCI edits, LCD and NCD coverage rules, payer-specific billing guidelines, and even medical necessity criteria. The more sophisticated the scrubber, the fewer denials you will see. If you are getting a lot of denials for issues that a scrubber should catch, like invalid codes, bundling errors, or missing modifiers, your scrubbing rules may need updating. CPT and ICD-10 codes change every year, and NCCI edits are updated quarterly. Make sure your scrubber is using current rule sets.