Much like the major finance institutions closely following the lead of the Federal Reserve, medical health insurance carriers stick to the lead of Medicare. Medicare is getting serious about filing medical claims electronically. Yes, avoiding hassles from Medicare is just one part of the puzzle. Have you thought about the commercial carriers? In case you are not fully utilizing all the electronic options at your disposal, you might be losing money. In this post, I am going to discuss five key electronic business processes that all major payers must support and just how you can use them to dramatically enhance 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 carry on and submit a very high amount of paper claims will get a Medicare “ask for documentation,” which should be completed within 45 days to ensure their eligibility to submit paper claims. Denials usually are not susceptible to appeal. In essence that in case you are not filing claims electronically, it can cost you additional time, money and hassles.
While we have seen much groaning and distress over new regulations and rules heaved upon us by HIPAA (the Insurance Portability and Accountability Act of 1996), you will find 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 offering five methods to optimize the claims process.
Practitioners frequently accept insurance cards that 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, a full 25 percent resulted from eligibility issues. Specifically, 22 percent resulted from coverage termination and coverage lapses. Eligibility denials not just create more work by means of research and rebilling, they also increase the risk of nonpayment. Poor eligibility verification increases the probability of failing to precertify with the correct carrier, which can then result in a clinical denial. Furthermore, time wasted as a result of incorrect eligibility verification can lead you to miss the carrier’s timely filing requirements.
Utilisation of the medical eligibility allows practitioners to automate this procedure, increasing the number of patients and procedures which can be 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. Taking 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 most providers is unknowingly providing services which are not “authorized” from the payer. Even though authorization is provided, it could be lost from the payer and denied as unauthorized until proof is provided. Researching the issue and giving proof for the carrier costs you money. The situation is a lot 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. With this electronic record of authorization, you will have the documentation you require in case there are questions about the timeliness of requests or actual approval of services. Yet another benefit from this automated precertification is a reduction in time as well as labor typically spent getting authorization via telephone or fax. With electronic authorization, your employees could have more time to obtain more procedures authorized and can have never trouble reaching a payer representative. Additionally, your staff will better identify out-of-network patients initially 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 may be beneficial to seek the help of a medical management vendor for support using this labor-intensive process.
Submitting claims electronically is easily the most fundamental process out from 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 cash flow, reduces the fee for claims processing and streamlines internal processes enabling you to focus on patient care. A paper insurance claim often 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 rise in cash designed for the needs of a growing practice. Reduced labor, office supplies and postage all play a role in the conclusion of your own practice when submitting claims electronically.
Continuous rebilling of unpaid claims creates denials for duplicate claims with each rebill processed by the payer – causing more be right for you and the carrier. Using the HIPAA electronic claim status standard offers an alternative choice to paying your staff to enjoy hours on the phone checking claim status. In addition to confirming claim receipt, you can even get details on the payment processing status. The reduction in denials lets your employees focus on more productive revenue recovery activities. You may use claim status information in your favor by optimizing the timing of your claim inquiries. For instance, once you learn that electronic remittance advice and payment are received within 21 days from a specific payer, it is possible to create a new claim inquiry process on day 22 for many claims in that batch which are still not posted.
HIPAA’s electronic remittance advice process can offer extremely valuable information to your practice. It can much not only keep your staff time and energy. 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 significant reason behind denials.
Another major reap the benefits of electronic remittance advice is the fact that all adjustments are posted. Without it 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 using the carriers. You can even require a proactive approach with 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 access to these electronic processes via their websites. With a simple Web connection, you are able to register at these web sites and possess real-time use of patient insurance information that was once available only by telephone. Even 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 as well as the learning curve are minimal.
Registering at no cost use of individual carrier websites can be a significant improvement over paper for your practice. The drawback to this particular approach is that your staff must continually log out and in of multiple websites. A more unified approach is by using a sensible practice management application that also includes full support for electronic data exchange using the carriers. Depending on the form of software you make use of, your choices and costs can vary greatly as to how you will submit claims. Medicare offers the solution to submit claims at no cost directly via dial-up connection.
Alternately, you may have the option to employ a clearinghouse that receives your claims for Medicare along with other carriers and submits them to suit your needs. Many software vendors dictate the clearinghouse you must use to submit claims. The fee is normally determined on the per-claim basis and will usually be negotiated, with prices starting around twenty-four cents per claim. While using billing software along with a clearinghouse is an efficient approach to streamline procedures and maximize collections, it is crucial 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 the claims by reviewing the various reports offered by the clearinghouses.
These systems automatically review electronic claims before these are sent out. They look for missing fields, misused modifiers, mismatched CPT and ICD-9 codes and generate a report of errors and omissions. The most effective systems will also examine your RVU sequencing to make sure maximum reimbursement.
This procedure gives the staff time to correct the claim before it is submitted, rendering it much less likely that this claim will likely be denied then have to be resubmitted. Remember, the carriers generate income the more time they can hold onto your payments. An excellent claim scrubber will help even playing field. All carriers use their own version of a claim scrubber when they receive claims from you.
With all the mandates from Medicare with all the other carriers following suit, you just do not want not to go electronic. All facets of the practice can be enhanced by the use of the HIPAA standards of electronic data exchange. As the initial investment in hardware, software and training could cost thousands of dollars, the correct utilization of the technology virtually guarantees a rapid return on your investment.