Clean Claims, Faster Reimbursements, Lower Denials — Proactive validation that combines advanced rule logic with clinical expertise.
At IntegraRCM, we help medical practices, specialty clinics, and hospitals turn their claim submission process into a first-line defense against denials, payer audits, and costly rework. Our claim scrubbing services go beyond simple error checks — we combine advanced rule logic with clinical context and payer-specific expertise to ensure claims are clean, compliant, and adjudicated quickly.
In a revenue cycle environment where payers are using automation to deny claims at scale and staffing shortages limit internal capacity, proactive claim scrubbing is no longer optional — it's essential for financial stability.
Before claims go to payers, they should be tested against payer policies, clinical logic, and submission rules. Claim scrubbing corrects issues with coding and modifier errors, invalid or missing eligibility data, misaligned diagnosis-procedure relationships, payer-specific compliance flags, and documentation gaps tied to medical necessity logic. When this verification doesn't happen, claims are denied immediately, creating costly downstream rework.
Automated engines catch thousands of technical edits, but many payer challenges are clinical or policy-specific. Our team reviews claims through a hybrid lens that understands specialty nuances, payer policy idiosyncrasies, and medical necessity expectations.
Instead of fixing claims one at a time, we identify denial patterns and upstream workflow issues that cause repeat failures. This reduces both rework and future denials through proactive prevention.
Our reporting doesn't stop at "this claim failed." We deliver root cause analysis, weekly trend dashboards, and actionable recommendations for front-end, mid-cycle, and back-end adjustments.
New regulatory changes for 2026 create both opportunities and audit risks. Our claim scrubbing service helps you stay compliant while maximizing reimbursement.
CMS continues pushing outpatient eligibility expansions as part of the Inpatient-Only (IPO) list phase-out for 2026. While this creates growth opportunities for outpatient and ASC settings, it brings new audit vectors.
Key Risk: Payers increasingly challenge whether a specific patient met outpatient appropriateness criteria, not just whether the CPT code is payable.
Effective Jan 1, 2026, the CMS Interoperability & Prior Authorization Final Rule requires impacted health plans to respond to urgent prior auth requests within 72 hours and standard requests within 7 days.
What this means: Track PA response times, ensure justification aligns with clinical/policy requirements, and anticipate heightened scrutiny on high-dollar procedures.
Many ASCs and hospital outpatient departments now face mandatory quality measure reporting with financial consequences (e.g., a 2% payment reduction for non-participation).
This makes upstream claims integrity even more critical for maintaining full reimbursement.
System Integration & Intake
Pre-Submission Rule Application
Human Review & Exception Resolution
Clinical Alignment Verification
Clean Submission
Feedback & Optimization
Comprehensive intake → automated + human validation → clinical context review → clean submission → continuous improvement feedback.
| Metric | Before IntegraRCM | After IntegraRCM |
|---|---|---|
| First-pass claim acceptance | Lower rate due to errors in claims | Higher clean-claim rate; fewer rejections |
| Days in A/R due to claim error | Extended by corrections/re-submissions | Shorter A/R; fewer re-submissions |
| Staff time spent correcting claims | High administrative burden | Reduced rework; focus on higher-value tasks |
| Write-offs from denied/untimely claims | Elevated in some specialties | Declined as fewer claims denied or delayed |
| Visibility into error trends | Limited or reactive | Proactive dashboards with root-cause trends |
Client: A 60-physician multi-specialty group (orthopedics, cardiology, imaging)
Challenge: High volume of rework due to coding mismatches and missing documentation; delays impacting cash flow.
Results (within 9 months):
Note: Results vary by payer mix, specialty, and system configuration. KPIs and SLAs are defined during onboarding and reported weekly/monthly.
| Model | Description | Suitable For |
|---|---|---|
| Per-Claim Fee | Fixed fee per claim processed (error flagging & correction coordination) | Clinics, smaller physician practices |
| Dedicated Team / FTE Model | Full-time team integrated with your workflow and systems | Hospitals, multi-location practices with high volume |
| Hybrid Model | Monthly retainer + per-claim fee for overflow/specialty claims | Practices with fluctuating volume or mixed service lines |
Each engagement begins with onboarding: baseline error audit, workflow mapping, integration setup, and KPI definition. SLAs include clean-claim improvement, scrubbing TAT, and reduction in corrections/resubmissions.
Typically, organizations see measurable improvements within the first quarter, with sustained gains over 6–12 months.
Complex coding scenarios across specialties require advanced scrubbing logic and clinical expertise.
High-value procedures with complex modifier requirements and frequent payer scrutiny.
Outpatient procedure documentation and medical necessity validation under IPO phase-out rules.
Session documentation, medical necessity criteria, and payer-specific authorization requirements.
Prospective payment system compliance and wraparound service documentation requirements.
Facility billing complexity, quality measure reporting, and compliance with changing CMS regulations.
Claim scrubbing is the review and validation of claims before submission — checking for demographic errors, coding issues, payer rule violations, and missing attachments — to maximize first-pass acceptance.
Payer policy changes, incorrect modifiers, missing documentation, demographic errors, or unverified eligibility can still cause denials. A structured scrubbing workflow catches issues ahead of submission.
We combine human review (coding & documentation) with rule-driven checks. Automation supports volume; human oversight ensures complex cases are handled correctly.
All specialties benefit, but high-volume/high-complexity (imaging, surgery, multi-site clinics, facility billing) often see the strongest gains.
Typically 60–90 days for error reduction and faster submission; broader AR/revenue impact commonly follows over 6–12 months.
Yes — we integrate with practice-management, billing, and clinical systems to enable seamless data flow and minimal disruption.
If your team is tired of chasing aged A/R, swimming in resubmissions, and getting "we'll get back to you" from payers, it's time for proactive claim scrubbing. We'll review a recent sample of submitted claims, identify coding/demographic/documentation errors, analyze payer-specific rejection causes, and deliver a baseline clean-claim rate with actionable recommendations.
Free claim quality assessments are typically delivered within 10 business days.