Similar to the major financial institutions closely following the lead of the Federal Reserve, health insurance carriers stick to the lead of Medicare. Medicare is getting interested in filing medical claims electronically. Yes, avoiding hassles from Medicare is only one part of the puzzle. What about the commercial carriers? Should you be not fully utilizing each of the electronic options at your disposal, you are losing money. In this post, I will discuss five key electronic business processes that all major payers must support and exactly 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 out filing electronically. Physicians who carry on and submit a high level of paper claims will receive 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 subjected to appeal. The end result is that should you be 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 first 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 ways 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. 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 by means of research and rebilling, in addition they increase the potential risk of nonpayment. Poor eligibility verification raises the probability of failing to precertify with all the correct carrier, which may then result in a clinical denial. Furthermore, time wasted because of incorrect eligibility verification can make you miss the carrier’s timely filing requirements.
Use of the check medi-cal eligibility allows practitioners to automate this process, increasing the amount of patients and operations which are correctly verified. This standard allows you to query eligibility multiple times throughout the patient’s care, from initial scheduling to billing. This sort of real-time feedback can help reduce billing problems. Using this process further, there is certainly a minumum of one vendor of practice management software that integrates automatic electronic eligibility into the practice management workflow.
A typical problem for most providers is unknowingly providing services which are not “authorized” through the payer. Even though 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 money. The problem is even more acute with HMOs. Without proper referral authorization, you risk providing free services by performing work that 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. Using this electronic record of authorization, you have the documentation you need just in case there are questions on the timeliness of requests or actual approval of services. An extra benefit from this automated precertification is a decrease in some time and labor typically spent getting authorization via telephone or fax. With electronic authorization, your employees will have additional time to get more procedures authorized and definately will not have trouble getting to a payer representative. Additionally, your employees will better identify out-of-network patients initially and also have a possiblity to request an exception. While extremely useful, electronic referral requests and authorizations are not yet fully implemented by all payers. It is a great idea to seek the help of a medical management vendor for support with this particular labor-intensive process.
Submitting claims electronically is the most fundamental process out from the five HIPPA tools. By processing your claims electronically you get priority processing. Your electronically submitted claims go right 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 cost of claims processing and streamlines internal processes allowing you to 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 decline in insurance reimbursement time results in a significant rise in cash readily available for the needs of a growing practice. Reduced labor, office supplies and postage all bring about the conclusion of the practice when submitting claims electronically.
Continuous rebilling of unpaid claims creates denials for duplicate claims with every rebill processed through the payer – causing more be right for you and also the carrier. Utilizing the HIPAA electronic claim status standard offers an alternative choice to paying your staff to invest hours on the phone checking claim status. As well as confirming claim receipt, you may also get details on the payment processing status. The decrease in denials lets your employees concentrate on more productive revenue recovery activities. You can utilize claim status information to your benefit by optimizing the timing of your own claim inquiries. As an example, if you know that electronic remittance advice and payment are received within 21 days from a specific payer, it is possible to set up a whole new claim inquiry process on day 22 for many claims because batch that are still not posted.
HIPAA’s electronic remittance advice process can provide extremely valuable information in your practice. It will much not only save your staff time and effort. It improves the timeliness and accuracy of postings. Reducing the time between payment and posting greatly reduces the occurrence of rebilling of open accounts – a significant reason for denials.
Another major take advantage of 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 excessively inflated A/R. This distortion also can make it more challenging so that you can identify denial patterns with the carriers. You can also take a proactive approach with the remittance advice data and begin a denial database to zero in on problem codes and problem carriers.
Due to HIPAA, virtually all major commercial carriers now provide free access to these electronic processes via their websites. Having a simple Internet connection, you are able to register at these web sites and have real-time access to patient insurance information that was once available only by telephone. Even the smallest practice should consider registering to confirm eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and update your provider profile. Registration time as well as the learning curve are minimal.
Registering at no cost access to individual carrier websites can be a significant improvement over paper to your practice. The drawback to this particular approach that the staff must continually log out and in of multiple websites. A 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 make use of, your choices and expenses may vary regarding how you submit claims. Medicare supplies the solution to submit claims at no cost directly via dial-up connection.
Alternately, you could have the choice to utilize a clearinghouse that receives your claims for Medicare and other carriers and submits them to suit your needs. Many software vendors dictate the clearinghouse you must use to submit claims. The price is generally 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 excellent way to streamline procedures and maximize collections, it is crucial ejbexv closely monitor the performance of your clearinghouse. Providers should instruct their staff to file claims at least three times a week and verify receipt of these claims by reviewing the different reports supplied by the clearinghouses.
These systems automatically review electronic claims before they may be sent out. They search for missing fields, misused modifiers, mismatched CPT and ICD-9 codes and produce a report of errors and omissions. The very best systems may also examine your RVU sequencing to make certain maximum reimbursement.
This procedure gives the staff time for you to correct the claim before it is actually submitted, making it much less likely the claim is going to be denied and after that must be resubmitted. Remember, the carriers make money the more they can hold onto your instalments. A good claim scrubber may help including the playing field. All carriers use their very own version of the claim scrubber when they receive claims from you.
With the mandates from Medicare along with all the other carriers following suit, you merely cannot afford to not go electronic. Every aspect of your practice can be enhanced by the use of the HIPAA standards of electronic data exchange. As the initial investment in hardware, software and training might cost hundreds and hundreds of dollars, the correct utilization of the technology virtually guarantees a rapid return on the investment.