Just 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 getting serious about filing medical claims electronically. Yes, avoiding hassles from Medicare is just one piece of the puzzle. Have you thought about the commercial carriers? If you are not fully utilizing all the electronic options at your disposal, you might be losing money. In this post, I will discuss five key electronic business processes that all major payers must support and how they are utilized to dramatically boost your bottom line. We’ll also explore options available for going electronic.
Medicare recently began putting some pressure on providers to start out filing electronically. Physicians who continue to submit a very high amount of paper claims will receive a Medicare “request documentation,” which must be completed within 45 days to verify their eligibility to submit paper claims. Denials are not subjected to appeal. The end result is that should you be not filing claims electronically, it will set you back extra time, money and hassles.
While there has been much groaning and distress over new regulations heaved upon us by HIPAA (the Health 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 by offering five methods to optimize the claims process.
Practitioners frequently accept insurance cards which can be invalid, expired, or even faked. The Medical Insurance Association of America (HIAA) found in a 2003 study that 14 percent of all claims were denied. Out of that percentage, an entire 25 percent resulted from eligibility issues. More specifically, 22 percent resulted from coverage termination and coverage lapses. Eligibility denials not only create more work in the form of research and rebilling, in addition they increase the chance of nonpayment. Poor eligibility verification increases the probability of neglecting to precertify with all the correct carrier, which can then result in a clinical denial. Furthermore, time wasted as a result of incorrect eligibility verification can cause you to miss the carrier’s timely filing requirements.
Utilization of the medi cal eligibility check allows practitioners to automate this procedure, increasing the amount of patients and operations that are correctly verified. This standard lets you query eligibility many times through the patient’s care, from initial scheduling to billing. This type of real-time feedback can greatly reduce billing problems. Taking this process even more, there is one or more vendor of practice management software that integrates automatic electronic eligibility in to the practice management workflow.
A typical problem for a lot of providers is unknowingly providing services which are not “authorized” from the payer. Even if authorization is provided, it could be lost by the payer and denied as unauthorized until proof is provided. Researching the matter and giving proof for the carrier costs you cash. The problem is much more acute with HMOs. Without the right referral authorization, you risk providing free services by performing work that is certainly outside the network.
The HIPAA referral request and authorization process allows providers to automate the requests and logging of authorization for most services. Using this electronic record of authorization, you have the documentation you need just in case you will find questions about the timeliness of requests or actual approval of services. An additional benefit from 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 time to obtain more procedures authorized and definately will have never trouble getting to a payer representative. Additionally, your staff will better identify out-of-network patients at first and have a opportunity to request an exception. While extremely useful, electronic referral requests and authorizations are certainly not yet fully implemented by all payers. It may be beneficial to seek the assistance of a medical management vendor for support using 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 obtain priority processing. Your electronically submitted claims go straight 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 income, reduces the fee for 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 reduction in insurance reimbursement time results in a significant increase in cash readily available for the requirements a growing 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 each rebill processed from the payer – causing more be right for you as well as the carrier. Utilizing the HIPAA electronic claim status standard offers an alternative choice to paying your employees to enjoy hours on the phone checking claim status. In addition to confirming claim receipt, you can even get details on the payment processing status. The reduction in denials lets your staff focus on more productive revenue recovery activities. You can utilize claim status information in your favor by optimizing the timing of your own claim inquiries. For instance, once you know that electronic remittance advice and payment are received within 21 days coming from a specific payer, you can create a new claim inquiry process on day 22 for all claims in that batch that are still not posted.
HIPAA’s electronic remittance advice process can offer extremely valuable information in your practice. It will much more than simply keep your staff time and energy. 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 significant reason for denials.
Another major benefit from electronic remittance advice is the fact that all adjustments are posted. Without this timely information, you data entry personnel may fail to post the “zero dollar payments,” resulting in an overly inflated A/R. This distortion also can make it more challenging for you to identify denial patterns using the carriers. You may also have a proactive approach with 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. Using a simple Internet connection, it is possible to register at these web sites and have real-time access to patient insurance information that was previously available only by telephone. Even the smallest practice should look into registering to ensure eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and enhance your provider profile. Registration time and the learning curve are minimal.
Registering at no cost use of individual carrier websites could be a significant improvement over paper for your practice. The drawback for this approach that the staff must continually log out and in of multiple websites. A more unified approach is to apply a sensible practice management application that also includes full support for electronic data exchange using the carriers. Depending on the kind of software you make use of, your choices and expenses can vary as to how you will submit claims. Medicare provides the solution to submit claims free of charge directly via dial-up connection.
Alternately, you may have the choice to utilize 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 fee is generally determined on a per-claim basis and may usually be negotiated, with prices starting around twenty-four cents per claim. While using billing software as well as a clearinghouse is an efficient approach to streamline procedures and maximize collections, it is necessary ejbexv closely monitor the performance of your own clearinghouse. Providers should instruct their staff to submit claims a minimum of three times a week and verify receipt of the claims by reviewing the many 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 very best systems will also examine your RVU sequencing to ensure maximum reimbursement.
This process provides the staff time and energy to correct the claim before it is submitted, rendering it less likely that the claim is going to be denied and then must be resubmitted. Remember, the carriers earn money the more they could hold on to your payments. A good claim scrubber can help including the playing field. All carriers use their very own version of any claim scrubber whenever they receive claims by you.
Using the mandates from Medicare with other carriers following suit, you just cannot afford to not go electronic. Every aspect of your own practice could be enhanced using the HIPAA standards of electronic data exchange. As the initial investment in hardware, software and training could cost hundreds and hundreds of dollars, the correct use of the technology virtually guarantees a fast return on the investment.