The cleanest claim is the one that gets paid on first submission. Every claim that goes out unclean is a claim that bounces back as a denial, costs an average of $25 to $118 to rework depending on complexity, and adds 14 to 21 days to the cash conversion cycle. For a typical U.S. hospital running a 9% denial rate, that volume of rework represents 5% to 7% of total billing operations cost.
RCMGen's standardized claim scrubbing service is structured to catch claim errors before submission, not after. Multi-layer edit checks across eligibility, authorization, coding, modifier usage, payer-specific rules, and medical necessity. Continuous rules updates as payer policies change. First-pass clean claim rates above 98%, sustained across the engagement.
RCMGen's standardized claim scrubbing runs every outbound claim through nine independent edit layers, each catching a distinct category of preventable denial.
Eligibility verification
Real-time payer eligibility check at point of service, re-verification at point of submission, and active coverage validation across primary and secondary payers.
Authorization verification
Prior authorization confirmation on file and valid, service-to-authorization matching, expiration date tracking, and unit count alignment with approved authorization scope.
Coding accuracy checks
ICD-10 and CPT code validation, code-to-diagnosis specificity, MUE unit limits, age and gender validation, and place-of-service alignment with billed service.
Modifier validation
Modifier required versus modifier prohibited by payer, modifier-CPT combination logic, payer-specific modifier rules, and modifier sequencing for multi-procedure claims.
NCCI bundling and unbundling
NCCI procedure-to-procedure edits, payer-specific bundling rules that exceed NCCI, correct unbundling with documented modifier support, etc.
Medical necessity
LCD and NCD coverage determinations for Medicare, medical policy alignment, documentation sufficiency flags, and diagnosis-to-procedure necessity validation.
Timely filing
Days-since-service tracking by payer, payer-specific filing window monitoring, escalation flags for claims deadline, and resubmission window preservation for denied claims.
Charge capture completeness
Missing charge detection, undercoded service flags, supply and implant capture validation, and ancillary service charge reconciliation against documented procedures.
Payer-specific rules layer
Each major payer's custom ruleset layered on top of generic edits, continuously updated as payer policies, medical policies, and edit logic change.
Who this service is for
Standardized claim scrubbing is valuable for any U.S. healthcare organization where the first-pass clean claim rate sits below 95% or the denial rate exceeds 8%. It is most valuable for:
- Hospitals running multiple payer contracts where payer-specific rules vary widely
- Multi-specialty physician groups where coding complexity varies by service line
- Critical access hospitals with limited internal billing capacity to keep up with rule changes
- Specialty practices in high-denial specialties (oncology, cardiology, orthopedics, behavioral health)
- Ambulatory surgery centers facing complex bundling and modifier requirements
- Federally qualified health centers managing multiple Medicaid plan rulesets
Get a free denial recovery report
Submit a deidentified denial export and receive a written 12-page diagnostic inside 5 business days. The report identifies which payers are costing you the most, which denial reason codes are driving the largest losses, and which aged denials are still recoverable. No PHI upload. No BAA. No contract.
