Similar to the major financial institutions closely following the lead of the Federal Reserve, health insurance carriers follow the lead of Medicare. Medicare is becoming interested in filing medical claims electronically. Yes, avoiding hassles from Medicare is only one piece of the puzzle. What about the commercial carriers? In case you are not fully utilizing all of the electronic options at your disposal, you might be losing money. In this post, I am going to discuss five key electronic business processes that all major payers must support and exactly how you can use them to dramatically enhance your bottom line. We’ll also explore available options for going electronic.
Medicare recently began putting some pressure on providers to begin filing electronically. Physicians who still submit a higher amount of paper claims will get a Medicare “request for documentation,” which has to be completed within 45 days to verify their eligibility to submit paper claims. Denials usually are not susceptible to appeal. The bottom line is that in case you are not filing claims electronically, it will set you back extra time, money and hassles.
While we have seen much groaning and distress over new regulations heaved upon us by HIPAA (the medical Insurance Portability and Accountability Act of 1996), there exists a silver lining. With HIPAA, Congress mandated the initial electronic data standards for routine business processes between insurance companies and providers. These new standards usher in a new era for providers through providing five ways to optimize the claims process.
Practitioners frequently accept insurance cards which are invalid, expired, or perhaps faked. The Insurance Association of America (HIAA) found in a 2003 study that 14 percent of all the claims were denied. Away from that percentage, a complete 25 % resulted from eligibility issues. More specifically, 22 percent resulted from coverage termination and/or coverage lapses. Eligibility denials not just create more work as research and rebilling, they also increase the chance of nonpayment. Poor eligibility verification increases the chance of neglecting to precertify using the correct carrier, which may 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.
Utilization of the check medical eligibility allows practitioners to automate this method, increasing the number of patients and operations which can be correctly verified. This standard enables you to query eligibility multiple times through the patient’s care, from initial scheduling to billing. This type of real-time feedback can greatly reduce billing problems. Using this process further, there is certainly one or more vendor of practice management software that integrates automatic electronic eligibility to the practice management workflow.
A standard problem for a lot of providers is unknowingly providing services which are not “authorized” by the payer. Even if authorization is given, it could be lost by the payer and denied as unauthorized until proof is provided. Researching the matter and giving proof to the carrier costs serious cash. The problem is even more acute with HMOs. Without the proper referral authorization, you risk providing free services by performing work that is outside the network.
The HIPAA referral request and authorization process allows providers to automate the requests and logging of authorization for most services. With this electronic record of authorization, you will have the documentation you require in the event there are questions about the timeliness of requests or actual approval of services. An additional benefit of this automated precertification is a reduction in time and labor typically spent getting authorization via telephone or fax. With electronic authorization, your staff could have more time to get additional procedures authorized and will have never trouble reaching a payer representative. Additionally, your employees will better identify out-of-network patients initially and also a possiblity to request an exception. While extremely useful, electronic referral requests and authorizations usually are not yet fully implemented by all payers. It may be beneficial to find the help of a medical management vendor for support with this labor-intensive process.
Submitting claims electronically is easily the most fundamental process out of the five HIPPA tools. By processing your claims electronically you get 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 cashflow, reduces the expense of claims processing and streamlines internal processes letting you focus on patient care. A paper insurance claim normally takes about 45 days for reimbursement, where average payment time for electronic claims is 14 days. The decrease in insurance reimbursement time results in a significant rise in cash designed for the requirements of an increasing practice. Reduced labor, office supplies and postage all bring about the important thing of the practice when submitting claims electronically.
Continuous rebilling of unpaid claims creates denials for duplicate claims with every rebill processed from the payer – causing more work for you as well as the carrier. Utilizing the HIPAA electronic claim status standard offers a substitute for paying your staff to invest hours on the phone checking claim status. In addition to confirming claim receipt, you can also get details on the payment processing status. The reduction in denials lets your staff focus on more productive revenue recovery activities. You may use claim status information to your advantage by optimizing the timing of the claim inquiries. As an example, once you know that electronic remittance advice and payment are received within 21 days coming from a specific payer, you are able to create a new claim inquiry process on day 22 for many claims in that batch which can be still not posted.
HIPAA’s electronic remittance advice process can offer extremely valuable information in your practice. It does much more than just keep your staff effort and time. It improves the timeliness and accuracy of postings. Decreasing 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 neglect to post the “zero dollar payments,” leading to an excessively inflated A/R. This distortion also can make it harder so that you can identify denial patterns with the carriers. You may also take a proactive approach with all the remittance advice data and start a denial database to zero in on problem codes and problem carriers.
Due to HIPAA, virtually all major commercial carriers now provide free use of these electronic processes via their websites. Having a simple Web connection, you can register at these websites and also have real-time access to patient insurance information that used to be available only on the phone. Including the smallest practice should consider registering to ensure eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and improve your provider profile. Registration some time and the learning curve are minimal.
Registering at no cost usage of individual carrier websites can be quite a significant improvement over paper for the practice. The drawback to this particular approach that the staff must continually log in and out of multiple websites. A more unified approach is to use a good practice management application that also includes full support for electronic data exchange using the carriers. Depending on the type of software you use, your options and costs can vary concerning how you submit claims. Medicare offers the solution to submit claims at no cost directly via dial-up connection.
Alternately, you could have the option to use a clearinghouse that receives your claims for Medicare along with other carriers and submits them for you personally. Many software vendors dictate the clearinghouse you must use to submit claims. The price is normally determined on a per-claim basis and may usually be negotiated, with prices starting around twenty-four cents per claim. While using the billing software and a clearinghouse is an efficient method to streamline procedures and maximize collections, it is crucial ejbexv closely monitor the performance of your clearinghouse. Providers should instruct their staff to submit claims at least 3 times each week and verify receipt of these claims by reviewing the different reports supplied by the clearinghouses.
These systems automatically review electronic claims before they are sent. They search for missing fields, misused modifiers, mismatched CPT and ICD-9 codes and generate a report of errors and omissions. The best systems may also check your RVU sequencing to make sure maximum reimbursement.
This procedure gives the staff time and energy to correct the claim before it is submitted, rendering it less likely the claim is going to be denied then must be resubmitted. Remember, the carriers earn money the more they are able to hold to your instalments. A good claim scrubber will help including the playing field. All carriers use their very own version of a claim scrubber once they receive claims from you.
Using the mandates from Medicare along with all other carriers following suit, you just do not want to not go electronic. All aspects of your own practice may be enhanced using the HIPAA standards of electronic data exchange. While the initial investment in hardware, software and training could cost hundreds and hundreds of dollars, the appropriate use of the technology virtually guarantees a rapid return on your investment.