Much like the major finance institutions closely following the lead of the Federal Reserve, medical health insurance carriers adhere to the lead of Medicare. Medicare is becoming interested in filing medical claims electronically. Yes, avoiding hassles from Medicare is only one part of the puzzle. How about the commercial carriers? If you are not fully utilizing all of the electronic options at your disposal, you might be losing money. In this article, I am going to discuss five key electronic business processes that all major payers must support and how they are utilized to dramatically enhance your bottom line. We’ll also explore possibilities for going electronic.
Medicare recently began putting some pressure on providers to begin filing electronically. Physicians who carry on and submit a high volume of paper claims will get a Medicare “request documentation,” which should be completed within 45 days to confirm their eligibility to submit paper claims. Denials are certainly not subject to appeal. The bottom line is that should you be not filing claims electronically, it can cost you extra time, money and hassles.
While there has been much groaning and distress over new regulations and rules heaved upon us by HIPAA (the Insurance Portability and Accountability Act of 1996), you will find a silver lining. With HIPAA, Congress mandated the first electronic data standards for routine business processes between insurance carriers and providers. These new standards usher in a new era for providers through providing five methods to optimize the claims process.
Practitioners frequently accept insurance cards which are invalid, expired, or perhaps faked. The Health Insurance Association of America (HIAA) found in a 2003 study that 14 percent of claims were denied. Away from that percentage, a full 25 percent resulted from eligibility issues. More specifically, 22 percent resulted from coverage termination and coverage lapses. Eligibility denials not merely create more work as research and rebilling, but they also increase the risk of nonpayment. Poor eligibility verification raises the chance of neglecting to precertify with all the correct carrier, which might then result in a clinical denial. Furthermore, time wasted because of incorrect eligibility verification can lead you to miss the carrier’s timely filing requirements.
Utilisation of the verify medical eligibility allows practitioners to automate this procedure, increasing the number of patients and procedures that are correctly verified. This standard lets you query eligibility several times during the patient’s care, from initial scheduling to billing. This type of real-time feedback can help reduce billing problems. Using this process further, there exists one or more vendor of practice management software that integrates automatic electronic eligibility into the practice management workflow.
A typical problem for many providers is unknowingly providing services which are not “authorized” from the payer. Even when authorization is offered, it may be lost from the payer and denied as unauthorized until proof is provided. Researching the matter and giving proof to the carrier costs you cash. The problem is a lot more acute with HMOs. Without the right referral authorization, you risk providing free services by performing work which is outside of the network.
The HIPAA referral request and authorization process allows providers to automate the requests and logging of authorization for many services. Using this electronic record of authorization, you will find the documentation you need just in case you will find questions regarding the timeliness of requests or actual approval of services. Yet another benefit of this automated precertification is a reduction in some time and labor typically spent getting authorization via telephone or fax. With electronic authorization, your employees will have more hours to get more procedures authorized and can not have trouble reaching a payer representative. Additionally, your employees will more effectively identify out-of-network patients at first and have a possiblity to request an exception. While extremely useful, electronic referral requests and authorizations usually are not yet fully implemented by all payers. It is a good idea to get the assistance of a medical management vendor for support with this labor-intensive process.
Submitting claims electronically is regarded as the fundamental process from the five HIPPA tools. By processing your claims electronically you obtain priority processing. Your electronically submitted claims go directly to the payer’s processing unit, ensuring faster turnaround. By contrast, paper claims are processed only after manual sorting and batching.
Processing insurance claims electronically improves cash flow, reduces the expense of claims processing and streamlines internal processes allowing you to concentrate on patient care. A paper insurance claim often takes about 45 days for reimbursement, in which the average payment time for electronic claims is 14 days. The decrease in insurance reimbursement time results in a significant boost in cash designed for the requirements a developing practice. Reduced labor, office supplies and postage all contribute to the important thing of your practice when submitting claims electronically.
Continuous rebilling of unpaid claims creates denials for duplicate claims with every rebill processed by the payer – causing more be right for you and the carrier. Using the HIPAA electronic claim status standard offers an alternative choice to paying your staff to spend hours on the phone checking claim status. In addition to confirming claim receipt, you may also get details on the payment processing status. The decrease in denials lets your staff give attention to more productive revenue recovery activities. You may use claim status information in your favor by optimizing the timing of the claim inquiries. For instance, if you know that electronic remittance advice and payment are received within 21 days coming from a specific payer, it is possible to create a brand new claim inquiry process on day 22 for many claims in that batch that are still not posted.
HIPAA’s electronic remittance advice process can provide extremely valuable information to your practice. It does much more than simply save your valuable staff time and effort. It improves the timeliness and accuracy of postings. Reducing the time between payment and posting greatly reduces the appearance of rebilling of open accounts – a major reason for denials.
Another major take advantage of electronic remittance advice is the fact that all adjustments are posted. Without it timely information, you data entry personnel may forget to post the “zero dollar payments,” resulting in an overly inflated A/R. This distortion also makes it more difficult so that you can identify denial patterns with the carriers. You may also take a proactive approach using the remittance advice data and start a denial database to zero in on problem codes and problem carriers.
Due to HIPAA, nearly all major commercial carriers now provide free use of these electronic processes via their websites. With a simple Internet connection, it is possible to register at these web sites and also have real-time usage of patient insurance information that was previously available only by phone. Even the smallest practice should look into registering to confirm eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and update your provider profile. Registration time and the educational curve are minimal.
Registering at no cost use of individual carrier websites could be a significant improvement over paper for the practice. The drawback for this approach is your staff must continually log out and in of multiple websites. A much more unified approach is to use a good practice management application which includes full support for electronic data exchange with the carriers. Depending on the kind of software you utilize, your alternatives and expenses may vary as to how you submit claims. Medicare provides the solution to submit claims at no cost directly via dial-up connection.
Alternately, you could have the choice to employ a clearinghouse that receives your claims for Medicare and other carriers and submits them for you personally. Many software vendors dictate the clearinghouse you must use to submit claims. The cost is generally determined on a per-claim basis and will usually be negotiated, with prices starting around twenty-four cents per claim. While using billing software along with a clearinghouse is an excellent approach to streamline procedures and maximize collections, it is crucial ejbexv closely monitor the performance of the clearinghouse. Providers should instruct their staff to submit claims at least 3 times per week and verify receipt of those claims by reviewing the various reports offered by the clearinghouses.
These systems automatically review electronic claims before they are sent out. They search for missing fields, misused modifiers, mismatched CPT and ICD-9 codes and generate a report of errors and omissions. The best systems will even check your RVU sequencing to make sure maximum reimbursement.
This method affords the staff time to correct the claim before it is submitted, making it much less likely that the claim is going to be denied and after that need to be resubmitted. Remember, the carriers earn money the more they could hold onto your instalments. A good claim scrubber can help even the playing field. All carriers use their particular version of the claim scrubber when they receive claims from you.
With the mandates from Medicare along with all other carriers following suit, you simply cannot afford to not go electronic. All aspects of your practice may be enhanced through the HIPAA standards of electronic data exchange. Whilst the initial investment in hardware, software and training might cost hundreds and hundreds of dollars, the appropriate utilisation of the technology virtually guarantees a rapid return on your own investment.