Charge Scrubbing Gap

Like a surgeon preparing for a procedure by thoroughly washing their hands up to the elbows (or further), your revenue cycle process should include a thorough “scrubbing” before your charges are finalized for submission to your payors. Charges that are already complete and compliant will be paid faster and reduce considerably your efforts to chase reimbursement. 

medaptus has worked with many customers and industry leaders to better understand charge workflow and charge scrubbing. We found some key areas to examine that might help make your whole revenue cycle process more efficient.

The Gap

Scrubbing charges is not a new concept. Most—if not all—organizations employ some kind of charge scrubbing software and workflow. The problems arise when the workflow is either incomplete or ineffective. That could be the case due to several circumstances.

Medical Coder

Medical coder at work.

The most important factor in allowing a gap with your scrubbing process is a breakdown in your feedback loop between coders, managers, and front-line charge documenters such as providers and nurses. Maintaining open and easy lines of communication between all phases of charge recording is the best way to create clean and compliant charges. If those recording the charge are not aware there is a problem, those problems will persist. Keep in mind, however, that there should also be a balance when providing feedback to the point of care. Providers do not want to be coders. Your feedback loop needs to find the appropriate balance between what needs to be done at the point of care and what can be done “on the back end”, so as not to overwhelm your clinical staff. It is typically when seeking that balance that a gap appears.

The feedback loop also suffers because of the generally linear revenue cycle process of the EHR. The charge is recorded, coders review the documentation and charges, charges are sent to billing, claims are sent to payors. Somewhere in the middle of those steps there needs to be communication between each of the departments to effect a required change. So the cycle should be circular, with multiple choices available at each point.

If your organization is managing multiple and varied revenue cycle workflows, your scrubbing process is likely to be inconsistent as well. As an organization grows or provides new services, your scrubbing process will need to scale to meet your new demands. If there is more than one process, scaling may be easily achieved, and gaps will appear.

Lastly, even though you may have fantastic coders, no coder can practically know absolutely all of the correct rules for all procedures and all services for all payors in all regions. Relying on coder knowledge alone represents a serious gap in your ability to create clean charges. Reliance on a manual process—instead of automation where available—can lead to avoidable financial risk.

Problems Associated with Poor Scrubbing

The first and most obvious result of poor scrubbing is claim denials. This has direct impact on your financial performance, but also has many possible downstream consequences. Incorrect claim coding will cause payor rejections and lower reimbursement rates. Operations become less efficient due to the additional tasks required for claim follow-up and adjudication. Provider reimbursement could also be affected and that may result in staff dissatisfaction. Scaling your organization for new services will be more difficult and less efficient.

Claim denials lead to “re-work”, which is much less efficient than being paid appropriately for the service from the start. The cost of adjudicating a rejected claim can be enormous, with some estimates as high as $25 per claim. Those costs can be much higher when following a payor appeal process. There will also be a corresponding reduction in charge and payment lag and AR days will increase. Additional resources will need to be deployed to address the issues, with work effort being repeatedly duplicated or redundant work being performed. Workflow bottlenecks cannot be identified or addressed. Of course, your organization may also run into compliance issues if the coding errors are egregious enough.

In short, the revenue cycle breaks down resulting in a huge impact on the entire organization.

Scrubbing Your Scrubber

The first step in addressing your scrubbing issues is to consolidate any differing workflows. Evaluate and document all workflows within your organization and determine your best practices. For a scrubbing solution to be efficient, it must be easily deployable to all departments, providing optimal efficiency for your organization. While coding requirements will differ depending on the services rendered, your workflow should be consistent and concise.

Best practice scrubbing workflows:

  • Be sure to include communication options into your scrubbing workflow, and be sure those methods have staff “buy-in.”
  • Agree on common communication method between coders and providers, whether that’s email or secure instant messaging. Ensure this communication method is available to be used by all staff and checked regularly.
  • Agree on preferred terminology and nomenclature so that communication errors are less likely to occur.
  • Have a terminology “cheat sheet” that can be incorporated into your training and workflow implementations.
  • There should be a “top down” reporting structure in place to emphasize your improved performance and close the feedback loop for denials.

Carefully monitor your claim denials to identify workflow bottlenecks, commonly occurring errors, and “frequent offenders”. Adjust your scrubbing process to remove these issues before claims are sent, providing a path for constant process improvement, and making your organization more efficient over time. Start with high-impact or high-volume problems, but realize the process is never ending. Rules are constantly changing, and you will likely encounter new issues regularly. Identify all rule exceptions and if possible, add them to your scrubbing process. 

If you are using scrubbing software of some kind, be sure to monitor existing “edits” to determine if they are up to date and accurate. Assess each of the rules used to determine if they are applicable across all departments or if they are somehow specialized.

Charge scrubbing software

Monitor existing “edits” if a charge scrubbing software is being used.

There needs to be consistent education for new providers and continuous education for existing providers. There is a balance to be achieved between a provider’s need to document and code correctly and their need to be made aware of every single coding regulation. That balance can be difficult to achieve but being able to rely on good communication and solid data can help to bridge that gap. Open communication among providers and coders, for instance, can lead to establishing ground rules for which issues might need a provider’s input and which might be tackled by coders alone. Remember, you want to have “buy in” so be realistic about what you are asking of providers. Another way to achieve buy-in among providers is to emphasize how their actions at the beginning of the revenue cycle can impact their RVU’s or compensation.

Scrubbing process improvement results:

  • “Scrubbing your scrubber” and creating a path of continuous improvement in your revenue cycle.
  • Fewer denials and receive appropriate reimbursement for all rendered services.
  • Higher productivity for coding and billing staff, less redundancy in charge adjudication procedures, and increased financial predictability with a corresponding reduction in risk.
  • Scalable solution as the organization grows and/or replaces resources.
  • Provider compensation will be appropriate, leading to higher staff satisfaction.

Start Now

Understand your denials. Begin prioritizing your biggest areas of concern. Those are typically higher reimbursement services or higher volume procedures. If your scrubber system allows for customized edit creation, employ that technology to specifically address your biggest issues. Create an edit for the problem and then discuss the required solution with your coders and providers to determine who would be better suited to implement a fix and at which point in the scrubbing process should that occur?

Fully document scrubber processes and directives. Are they all still relevant and necessary? When were they created and why? Are they still accurate? Are they applicable across all specialties and departments?

Evaluate your current feedback loop and reporting structure. Does it provide consistent communication between all parties? Is the communication infrastructure available to everyone? Do you have a standard set of terms? Is it working? Are providers included in discussions about coding issues and their own responsibilities?

Finally, evaluate all automation options. Be sure your scrubbing software can be easily incorporated into everyone’s workflow, using their existing hardware if practical. Make certain your scrubbing software can account for custom payor rules, regional payor differences, specialty-specific coding, and your own custom rule requirements. Being able to scrub for the standard sets of rules from CMS is no longer good enough. Your organization should be able to create a rule based on any or all information required to submit a claim. Your scrubber should be able to isolate coding exceptions, issue reports detailing coding and charge issues, and provide an easily accessible communication tool for feedback.

Effective charge scrubbing is not something which can be “turned on” and then forgotten. The process requires constant monitoring and updating as your organization expands and your personnel changes. But with effective tools and workflows, the gaps can be dramatically reduced or even eliminated. You will be able to track your own effectiveness through real-time reporting. Problems can be identified and actionable as soon as soon as they appear. With the appropriate responsibility assigned, behavior can be modified to meet your goals. Employee training will be clear and consistent, and your solutions can easily be scaled for new or different services provided. Putting it all together means fewer denials, clearer assignment of responsibilities, and improved staff satisfaction.

Related Blogs:

How to fill mid-revenue cycle gaps in your EHR – Part 1: Reconciliation

How to fill mid-revenue cycle gaps in your EHR | Part 2: Scalability


About the Author

Gary Bernklow

Senior Product Director

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