Just 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 becoming seriously interested in filing medical claims electronically. Yes, avoiding hassles from Medicare is only one piece of the puzzle. What about the commercial carriers? If you are not fully utilizing all of the electronic options at your disposal, you might be losing money. In the following paragraphs, I am going to discuss five key electronic business processes that all major payers must support and how you can use them to dramatically improve your bottom line. We’ll also explore options available for going electronic.
Medicare recently began putting some pressure on providers to start filing electronically. Physicians who carry on and submit a higher volume of paper claims will get a Medicare “request for documentation,” which should be completed within 45 days to ensure their eligibility to submit paper claims. Denials are not subject to appeal. The end result is that if you are not filing claims electronically, it will set you back additional 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), you will find a silver lining. With HIPAA, Congress mandated the very first electronic data standards for routine business processes between insurance carriers and providers. These new standards usher in a new era for providers through providing five approaches 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 claims were denied. Away from that percentage, an entire 25 % resulted from eligibility issues. Specifically, 22 percent resulted from coverage termination and coverage lapses. Eligibility denials not only create more work as research and rebilling, but they also increase the risk of nonpayment. Poor eligibility verification increases the probability of neglecting to precertify with the correct carrier, which might then result in a clinical denial. Furthermore, time wasted as a result of incorrect eligibility verification can make you miss the carrier’s timely filing requirements.
Utilization of the insurance verification companies allows practitioners to automate this method, increasing the number of patients and operations which are correctly verified. This standard allows you to query eligibility several times during the patient’s care, from initial scheduling to billing. This type 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 in to the practice management workflow.
A standard problem for many providers is unknowingly providing services that are not “authorized” through the payer. Even when authorization is offered, it might be lost from the payer and denied as unauthorized until proof is provided. Researching the matter and giving proof for the carrier costs serious cash. The circumstance is much more acute with HMOs. Without the right 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 a lot of services. With this electronic record of authorization, you will have the documentation you need just in case you can find questions about the timeliness of requests or actual approval of services. Yet another advantage of this automated precertification is a reduction in time as well as labor typically spent getting authorization via telephone or fax. With electronic authorization, your staff may have additional time to get more procedures authorized and definately will have never trouble reaching a payer representative. Additionally, your staff will more effectively identify out-of-network patients in the beginning and also have a chance 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 find the assistance of a medical management vendor for support with this particular labor-intensive process.
Submitting claims electronically is easily the most fundamental process out of the five HIPPA tools. By processing your claims electronically you receive 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 expense of 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 the average payment time for electronic claims is 14 days. The decline in insurance reimbursement time results in a significant increase in cash readily available for the requirements an increasing practice. Reduced labor, office supplies and postage all bring about the bottom line 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 work for you and also the carrier. Using 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 advantage by optimizing the timing of the claim inquiries. As an example, once you learn that electronic remittance advice and payment are received within 21 days from the specific payer, it is possible to create a new claim inquiry process on day 22 for all claims because batch which are still not posted.
HIPAA’s electronic remittance advice process can offer extremely valuable information for your practice. It can much more than simply save your valuable staff time and effort. It increases the timeliness and accuracy of postings. Decreasing the time between payment and posting greatly reduces the appearance of rebilling of open accounts – a major cause of denials.
Another major benefit from electronic remittance advice is the fact that all adjustments are posted. Without it timely information, you data entry personnel may forget to post the “zero dollar payments,” resulting in an excessively inflated A/R. This distortion also causes it to be more challenging that you should identify denial patterns with all the carriers. You can also have a proactive approach using the remittance advice data and begin a denial database to zero in on problem codes and problem carriers.
Because of HIPAA, nearly all major commercial carriers now provide free usage of these electronic processes via their websites. Using a simple Internet access, you can register at these websites and also have real-time usage of patient insurance information that was previously 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 some time and the training 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 approach that the staff must continually log in and out of multiple websites. A far more unified approach is by using a sensible practice management application that also includes full support for electronic data exchange with the carriers. Depending on the type of software you use, your alternatives and costs may vary regarding how you submit claims. Medicare provides the solution to submit claims free of charge directly via dial-up connection.
Alternately, you may have the choice to use 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 need to use to submit claims. The fee is usually determined over 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 way to streamline procedures and maximize collections, it is necessary ejbexv closely monitor the performance of your clearinghouse. Providers should instruct their staff to submit claims at least 3 x per week and verify receipt of these claims by reviewing the various reports supplied by the clearinghouses.
These systems automatically review electronic claims before they may be sent out. They look for missing fields, misused modifiers, mismatched CPT and ICD-9 codes and produce a report of errors and omissions. The very best systems will even examine your RVU sequencing to make sure maximum reimbursement.
This method gives the staff time and energy to correct the claim before it is actually submitted, making it far less likely the claim will be denied then must be resubmitted. Remember, the carriers make money the more they are able to hold on to your payments. An excellent claim scrubber may help even playing field. All carriers use their particular version of a claim scrubber when they receive claims on your part.
With all the mandates from Medicare along with all other carriers following suit, you just do not want to never go electronic. All aspects of your practice could be enhanced through 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 rapid return on the investment.