Similar to the major finance institutions closely pursuing the lead of the Federal Reserve, medical insurance carriers adhere to the lead of Medicare. Medicare is becoming 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 all 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 just 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 filing electronically. Physicians who continue to submit a higher level of paper claims will receive a Medicare “ask for documentation,” which must be completed within 45 days to verify their eligibility to submit paper claims. Denials are not subject 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 we have seen much groaning and distress over new regulations and rules heaved upon us by HIPAA (the Health Insurance Portability and Accountability Act of 1996), there is 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 providing five ways to optimize the claims process.
Practitioners frequently accept insurance cards that are invalid, expired, or even faked. The Health Insurance Association of America (HIAA) found in a 2003 study that 14 percent of claims were denied. From that percentage, a complete 25 percent resulted from eligibility issues. More specifically, 22 percent resulted from coverage termination and coverage lapses. Eligibility denials not just create more work as research and rebilling, but they also increase the risk of nonpayment. Poor eligibility verification boosts the probability of failing to precertify with the correct carrier, which can 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 electronic eligibility verification allows practitioners to automate this procedure, increasing the quantity of patients and procedures which can be correctly verified. This standard lets you query eligibility many times throughout the patient’s care, from initial scheduling to billing. This type 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 into the practice management workflow.
A typical problem for a lot of providers is unknowingly providing services that are not “authorized” through the payer. Even when authorization is offered, it could 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 situation 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 many services. Using this electronic record of authorization, you will find the documentation you will need in case you can find questions regarding the timeliness of requests or actual approval of services. Yet another benefit from this automated precertification is a reduction in 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 not have trouble arriving at a payer representative. Additionally, your staff will more effectively identify out-of-network patients in the beginning and also have a possiblity to request an exception. While extremely useful, electronic referral requests and authorizations are certainly not yet fully implemented by all payers. It is a good idea to find the help of a medical management vendor for support with this particular labor-intensive process.
Submitting claims electronically is easily the most fundamental process from 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 cash flow, reduces the cost of claims processing and streamlines internal processes allowing you to concentrate on patient care. A paper insurance claim normally takes about 45 days for reimbursement, in which the average payment time for electronic claims is 14 days. The reduction in insurance reimbursement time results in a significant increase in cash designed for the requirements of a developing practice. Reduced labor, office supplies and postage all contribute to the important thing of the practice when submitting claims electronically.
Continuous rebilling of unpaid claims creates denials for duplicate claims with every rebill processed by the payer – causing more be right for you and also the carrier. Utilizing the HIPAA electronic claim status standard offers a substitute for paying your staff to invest hours on the phone checking claim status. Along with confirming claim receipt, you can also get details on the payment processing status. The reduction in denials lets your employees focus on more productive revenue recovery activities. You can utilize claim status information to your advantage by optimizing the timing of your claim inquiries. For example, if you know that electronic remittance advice and payment are received within 21 days from the specific payer, you are able to setup a new claim inquiry process on day 22 for all claims because batch that are still not posted.
HIPAA’s electronic remittance advice process provides extremely valuable information to your practice. It does much not only save your valuable 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 – a significant reason behind denials.
Another major benefit from electronic remittance advice is the fact all adjustments are posted. Without this timely information, you data entry personnel may forget to post the “zero dollar payments,” resulting in an overly inflated A/R. This distortion also makes it more difficult for you to identify denial patterns using the carriers. You can also take a proactive approach using the remittance advice data and commence a denial database to zero in on problem codes and problem carriers.
Due to HIPAA, nearly all major commercial carriers now provide free usage of these electronic processes via their websites. Using a simple Internet connection, you can register at websites like these and have real-time access to patient insurance information that was previously available only by phone. Including the smallest practice should think about registering to verify eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and update your provider profile. Registration time and the educational curve are minimal.
Registering for free usage of individual carrier websites can be a significant improvement over paper to your practice. The drawback for this approach is your staff must continually log in and out of multiple websites. A much more unified approach is by using a sensible practice management application that includes full support for electronic data exchange with all the carriers. Depending on the type of software you use, your options and costs may vary regarding the way you submit claims. Medicare provides the option to submit claims free of charge directly via dial-up connection.
Alternately, you might have an opportunity to employ a clearinghouse that receives your claims for Medicare as well as other carriers and submits them for you. Many software vendors dictate the clearinghouse you have to use to submit claims. The price is usually determined over a per-claim basis and will usually be negotiated, with prices starting around twenty-four cents per claim. While using the billing software and a clearinghouse is an excellent 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 at least three times a week and verify receipt of those claims by reviewing the different reports provided by the clearinghouses.
These systems automatically review electronic claims before these are sent. They check 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 look at your RVU sequencing to ensure maximum reimbursement.
This method gives the staff time and energy to correct the claim before it is submitted, making it less likely the claim is going to be denied and after that need to be resubmitted. Remember, the carriers earn money the more they are able to hold onto your payments. A great claim scrubber can help including the playing field. All carriers use their particular version of any claim scrubber whenever they receive claims by you.
With the mandates from Medicare with all other carriers following suit, you simply cannot afford to never go electronic. Every aspect of the practice may be enhanced by the use of the HIPAA standards of electronic data exchange. As the initial investment in hardware, software and training might cost thousands of dollars, the appropriate utilisation of the technology virtually guarantees a fast return on your own investment.