Just like the major financial institutions closely following the lead of the Federal Reserve, health insurance carriers follow the lead of Medicare. Medicare is getting seriously interested in filing medical claims electronically. Yes, avoiding hassles from Medicare is just one piece of the puzzle. How about the commercial carriers? In case you are not fully utilizing all the electronic options at your disposal, you might be losing money. In this article, I will discuss five key electronic business processes that all major payers must support and just how they are utilized to dramatically boost your bottom line. We’ll also explore possibilities for going electronic.
Medicare recently began putting some pressure on providers to start filing electronically. Physicians who carry on and submit a high volume of paper claims will receive a Medicare “ask for documentation,” which should be completed within 45 days to verify their eligibility to submit paper claims. Denials are not susceptible to appeal. The bottom line is that if you are not filing claims electronically, it will 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 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 carriers 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 are invalid, expired, or even faked. The Medical Insurance Association of America (HIAA) found in a 2003 study that 14 percent of all the claims were denied. From that percentage, an entire 25 % resulted from eligibility issues. More specifically, 22 percent resulted from coverage termination or coverage lapses. Eligibility denials not only create more work as research and rebilling, they also increase the potential risk of nonpayment. Poor eligibility verification raises the probability of neglecting to precertify with all the correct carrier, which might then result in a clinical denial. Furthermore, time wasted due to incorrect eligibility verification can lead you to miss the carrier’s timely filing requirements.
Utilisation of the insurance verification companies allows practitioners to automate this method, increasing the number of patients and operations that are correctly verified. This standard enables you to query eligibility many times during the patient’s care, from initial scheduling to billing. This sort of real-time feedback can help reduce billing problems. Using 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 most providers is unknowingly providing services that are not “authorized” from the payer. Even if authorization is offered, it might be lost by the payer and denied as unauthorized until proof is provided. Researching the matter and giving proof towards the carrier costs you cash. The problem is even more acute with HMOs. Without the proper 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 a lot of services. With this particular electronic record of authorization, you will find the documentation you require just in case you can find questions regarding the timeliness of requests or actual approval of services. An additional benefit from this automated precertification is a reduction in time as well as labor typically spent getting authorization via telephone or fax. With electronic authorization, your employees will have more time to get more procedures authorized and definately will not have trouble arriving at 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 is a great idea to seek the assistance of a medical management vendor for support using this labor-intensive process.
Submitting claims electronically is regarded as the fundamental process out of the five HIPPA tools. By processing your claims electronically you receive 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 allowing you to focus on patient care. A paper insurance claim often 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 boost in cash designed for the needs of a developing practice. Reduced labor, office supplies and postage all contribute to the conclusion of your own practice when submitting claims electronically.
Continuous rebilling of unpaid claims creates denials for duplicate claims with every rebill processed through the payer – causing more meet your needs and also the carrier. Making use of 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 can even get details on the payment processing status. The decrease in denials lets your employees concentrate on more productive revenue recovery activities. You may use claim status information in your favor by optimizing the timing of your own claim inquiries. As an example, once you know that electronic remittance advice and payment are received within 21 days from the specific payer, you can create a brand new claim inquiry process on day 22 for those claims in that batch that are still not posted.
HIPAA’s electronic remittance advice process provides extremely valuable information for your practice. It can much not only save your valuable staff time and energy. It improves the timeliness and accuracy of postings. Decreasing the time between payment and posting greatly reduces the occurrence of rebilling of open accounts – an important reason for denials.
Another major reap the benefits of electronic remittance advice is the fact all adjustments are posted. Without it timely information, you data entry personnel may fail to post the “zero dollar payments,” leading to an overly inflated A/R. This distortion also can make it harder so that you can identify denial patterns with all 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.
Because of HIPAA, almost all major commercial carriers now provide free usage of these electronic processes via their websites. Having a simple Internet connection, you can register at these web sites and also have real-time access to patient insurance information that was once available only by telephone. Even the smallest practice should consider registering to verify eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and improve your provider profile. Registration time and the training curve are minimal.
Registering free of charge usage of individual carrier websites could be a significant improvement over paper for the practice. The drawback to this particular approach is your staff must continually log inside and out of multiple websites. A far more unified approach is to use a good practice management application that includes full support for electronic data exchange using the carriers. Depending on the kind of software you use, your choices and expenses may vary concerning the way you submit claims. Medicare provides the option to submit claims at no cost directly via dial-up connection.
Alternately, you might have an opportunity to utilize a clearinghouse that receives your claims for Medicare as well as other carriers and submits them to suit your needs. Many software vendors dictate the clearinghouse you need to use to submit claims. The fee is normally determined on a per-claim basis and can usually be negotiated, with prices starting around twenty-four cents per claim. While using the billing software as well as a clearinghouse is an efficient way to streamline procedures and maximize collections, it is important ejbexv closely monitor the performance of the clearinghouse. Providers should instruct their staff to submit claims a minimum of 3 x each week and verify receipt of the claims by reviewing the different reports offered by the clearinghouses.
These systems automatically review electronic claims before they are sent out. They check for missing fields, misused modifiers, mismatched CPT and ICD-9 codes and produce a report of errors and omissions. The very best systems will also examine your RVU sequencing to make certain maximum reimbursement.
This procedure provides the staff time to correct the claim before it is submitted, which makes it less likely that this claim is going to be denied and then need to be resubmitted. Remember, the carriers earn money the more they can hold onto your payments. A great claim scrubber can help even playing field. All carriers use their very own version of any claim scrubber once they receive claims from you.
With all the mandates from Medicare along with all other carriers following suit, you merely cannot afford to never go electronic. All aspects of your practice could 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 correct utilization of the technology virtually guarantees a fast return on the investment.