Much like the major financial institutions closely following the lead of the Federal Reserve, medical insurance carriers stick to the lead of Medicare. Medicare is getting interested in filing medical claims electronically. Yes, avoiding hassles from Medicare is just one part 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 post, I will 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 possibilities for going electronic.
Medicare recently began putting some pressure on providers to start filing electronically. Physicians who still submit a high amount of paper claims will get a Medicare “request for documentation,” which should be completed within 45 days to confirm their eligibility to submit paper claims. Denials usually are not subjected to appeal. In essence 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 Insurance Portability and Accountability Act of 1996), there is 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 by providing five methods to optimize the claims process.
Practitioners frequently accept insurance cards which can be invalid, expired, or even faked. The Health 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. Specifically, 22 percent resulted from coverage termination and/or coverage lapses. Eligibility denials not merely create more work in the form of research and rebilling, in addition they increase the potential risk of nonpayment. Poor eligibility verification raises the chance of neglecting 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 make you miss the carrier’s timely filing requirements.
Utilisation of the check medi-cal eligibility allows practitioners to automate this method, increasing the quantity of patients and operations which are correctly verified. This standard lets you query eligibility several times through the patient’s care, from initial scheduling to billing. This kind of real-time feedback can help reduce billing problems. Taking this process further, there is one or more vendor of practice management software that integrates automatic electronic eligibility to the practice management workflow.
A typical problem for many providers is unknowingly providing services that are not “authorized” by the payer. Even if authorization is offered, it may be lost by the payer and denied as unauthorized until proof is provided. Researching the matter and giving proof to the carrier costs serious cash. The problem is much more acute with HMOs. Without the right referral authorization, you risk providing free services by performing work that is away from 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 find the documentation you will need in the event you will find questions regarding the timeliness of requests or actual approval of services. Yet another advantage of this automated precertification is a reduction in some time and labor typically spent getting authorization via telephone or fax. With electronic authorization, your staff could have more time to get additional procedures authorized and will have never trouble getting to a payer representative. Additionally, your employees will more effectively identify out-of-network patients in the beginning and also 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 get the help of a medical management vendor for support using this 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 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 expense 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, where average payment time for electronic claims is 14 days. The decrease in insurance reimbursement time results in a significant boost in cash available for the requirements an increasing practice. Reduced labor, office supplies and postage all bring about the bottom line of your 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 as well as the carrier. Using the HIPAA electronic claim status standard offers an alternative choice to paying your employees to enjoy hours on the phone checking claim status. Along with confirming claim receipt, you may also get details on the payment processing status. The decrease in denials lets your staff focus 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 a specific payer, you can set up a brand new claim inquiry process on day 22 for all claims in this batch which are still not posted.
HIPAA’s electronic remittance advice process can provide extremely valuable information for your practice. It can much more than just keep your staff time and effort. It improves the timeliness and accuracy of postings. Lowering the time between payment and posting greatly reduces the appearance of rebilling of open accounts – a significant reason for 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,” causing an excessively inflated A/R. This distortion also can make it more difficult so that you can identify denial patterns using the carriers. You can also take 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, nearly all major commercial carriers now provide free use of these electronic processes via their websites. Having a simple Internet access, you can register at websites like these and have real-time access to patient insurance information that was previously available only on the phone. Even the smallest practice should look into registering to verify eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and enhance your provider profile. Registration some time and the educational curve are minimal.
Registering at no cost use of individual carrier websites can be a significant improvement over paper for the practice. The drawback to this particular approach is that your staff must continually log in and out of multiple websites. A far more unified approach is by using a sensible practice management application which includes full support for electronic data exchange with all the carriers. Depending on the form of software you utilize, your choices and expenses may vary concerning how you will submit claims. Medicare provides the choice to submit claims at no cost directly via dial-up connection.
Alternately, you might have the choice 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 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 billing software and a clearinghouse is an efficient approach to streamline procedures and maximize collections, it is necessary ejbexv closely monitor the performance of your clearinghouse. Providers should instruct their staff to file claims at the very least 3 x a week and verify receipt of these 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 very best systems will even look at your RVU sequencing to make sure maximum reimbursement.
This process affords the staff time for you to correct the claim before it is actually submitted, making it much less likely that the claim will likely be denied and after that must be resubmitted. Remember, the carriers make money the more they are able to hold to your payments. An excellent claim scrubber may help even 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 just cannot afford to never go electronic. Every aspect of your own practice can be enhanced through the HIPAA standards of electronic data exchange. Whilst the initial investment in hardware, software and training might cost thousands of dollars, the appropriate use of the technology virtually guarantees a fast return on your own investment.