Much like the major financial institutions closely pursuing the lead of the Federal Reserve, medical health insurance carriers stick to 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. What about the commercial carriers? In case you are not fully utilizing each of 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 exactly how you can use them to dramatically boost 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 continue to submit a higher amount of paper claims will get a Medicare “request documentation,” which has to be completed within 45 days to ensure their eligibility to submit paper claims. Denials are not subjected to appeal. The end result is that if you are not filing claims electronically, it will set you back more time, money and hassles.
While we have seen much groaning and distress over new regulations and rules heaved upon us by HIPAA (the medical 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 by offering five ways to optimize the claims process.
Practitioners frequently accept insurance cards which can be invalid, expired, or even faked. The Insurance Association of America (HIAA) found in a 2003 study that 14 percent of all the claims were denied. Out of that percentage, a complete 25 percent resulted from eligibility issues. Specifically, 22 percent resulted from coverage termination and/or coverage lapses. Eligibility denials not only create more work in the form of research and rebilling, in addition they increase the potential risk of nonpayment. Poor eligibility verification boosts the likelihood of failing to precertify with all the correct carrier, which might 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.
Utilisation of the mass health insurance eligibility allows practitioners to automate this method, increasing the number of patients and procedures that are correctly verified. This standard enables you to query eligibility multiple times during the patient’s care, from initial scheduling to billing. This sort of real-time feedback can help reduce billing problems. Taking this process even more, there exists at least one vendor of practice management software that integrates automatic electronic eligibility in to the practice management workflow.
A standard problem for a lot of providers is unknowingly providing services which are not “authorized” through the payer. Even though authorization is provided, it may be lost by the payer and denied as unauthorized until proof is offered. Researching the issue and giving proof towards the carrier costs you cash. The circumstance is a lot more acute with HMOs. Without the right 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 many services. With this electronic record of authorization, you will have the documentation you need just in case you can find questions regarding the timeliness of requests or actual approval of services. An extra advantage of this automated precertification is a decrease in time as well as labor typically spent getting authorization via telephone or fax. With electronic authorization, your staff could have additional time to get more procedures authorized and can never have trouble reaching a payer representative. Additionally, your staff will more effectively identify out-of-network patients in the beginning and also have a opportunity to request an exception. While extremely useful, electronic referral requests and authorizations are not yet fully implemented by all payers. It may be beneficial to find the assistance of a medical management vendor for support with this particular labor-intensive process.
Submitting claims electronically is the most 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 cashflow, reduces the fee for claims processing and streamlines internal processes letting you give attention to patient care. A paper insurance claim often takes about 45 days for reimbursement, where the average payment time for electronic claims is 14 days. The decrease in insurance reimbursement time results in a significant rise in cash available for the needs of an increasing 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 be right for you and also the carrier. Making use of 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 decrease in denials lets your staff give attention to more productive revenue recovery activities. You can utilize claim status information in your favor by optimizing the timing of your claim inquiries. For example, if you know that electronic remittance advice and payment are received within 21 days coming from a specific payer, it is possible to set up a whole new claim inquiry process on day 22 for those claims in this batch that are still not posted.
HIPAA’s electronic remittance advice process can provide extremely valuable information in your practice. It can much more than just save your staff effort and time. It improves the timeliness and accuracy of postings. Reducing the time between payment and posting greatly reduces the occurrence of rebilling of open accounts – an important reason behind denials.
Another major benefit from electronic remittance advice is that all adjustments are posted. Without this timely information, you data entry personnel may neglect to post the “zero dollar payments,” resulting in an excessively inflated A/R. This distortion also makes it more difficult so that you can identify denial patterns with all the carriers. You can also have a proactive approach with all the remittance advice data and start a denial database to zero in on problem codes and problem carriers.
Thanks to HIPAA, almost all major commercial carriers now provide free usage of these electronic processes via their websites. With a simple Web connection, it is possible to register at these websites and have real-time usage of patient insurance information that was once available only by telephone. Even the smallest practice should think about registering to confirm 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 at no cost access to individual carrier websites can be quite 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 much 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 alternatives and costs can vary greatly concerning the way you submit claims. Medicare supplies the option to submit claims free of charge directly via dial-up connection.
Alternately, you might have the choice to employ a clearinghouse that receives your claims for Medicare along with other carriers and submits them for you. Many software vendors dictate the clearinghouse you need to use to submit claims. The price is usually determined over a per-claim basis and may usually be negotiated, with prices starting around twenty-four cents per claim. When 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 the clearinghouse. Providers should instruct their staff to submit claims a minimum of 3 times each week and verify receipt of the claims by reviewing the many reports supplied by the clearinghouses.
These systems automatically review electronic claims before these are sent. They look for missing fields, misused modifiers, mismatched CPT and ICD-9 codes and produce a report of errors and omissions. The best systems may also examine your RVU sequencing to make certain maximum reimbursement.
This process provides the staff time and energy to correct the claim before it is actually submitted, which makes it far less likely the claim is going to be denied and then need to be resubmitted. Remember, the carriers generate income the more they can hold to your payments. A great claim scrubber can help even playing field. All carriers use their own version of any claim scrubber once they receive claims on your part.
Using the mandates from Medicare and with all the other carriers following suit, you merely do not want to never go electronic. All aspects of your own practice could be enhanced by the use of the HIPAA standards of electronic data exchange. While the initial investment in hardware, software and training could cost tens of thousands of dollars, the correct use of the technology virtually guarantees a fast return on your investment.