Much like the major financial institutions closely pursuing the lead of the Federal Reserve, health insurance carriers follow the lead of Medicare. Medicare is becoming serious about filing medical claims electronically. Yes, avoiding hassles from Medicare is only one piece of the puzzle. How about the commercial carriers? In case you are not fully utilizing all of the electronic options at your disposal, you are losing money. In this post, I will discuss five key electronic business processes that all major payers must support and just how they are utilized 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 out filing electronically. Physicians who still submit a high level of paper claims will get a Medicare “ask for documentation,” which must be completed within 45 days to confirm their eligibility to submit paper claims. Denials usually are not susceptible to appeal. In essence that if you are not filing claims electronically, it can cost you 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 exists a silver lining. With HIPAA, Congress mandated the initial 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 ways to optimize the claims process.
Practitioners frequently accept insurance cards which can be invalid, expired, or perhaps faked. The Health Insurance Association of America (HIAA) found in a 2003 study that 14 percent of all claims were denied. Out of that percentage, an entire 25 percent resulted from eligibility issues. More specifically, 22 percent resulted from coverage termination and coverage lapses. Eligibility denials not only create more work by means of research and rebilling, but they also increase the chance of nonpayment. Poor eligibility verification raises the probability of neglecting to precertify using the correct carrier, which can then result in a clinical denial. Furthermore, time wasted due to incorrect eligibility verification can cause you to miss the carrier’s timely filing requirements.
Use of the medical eligibility check allows practitioners to automate this process, increasing the number of patients and operations which can be correctly verified. This standard enables you to query eligibility many times throughout the patient’s care, from initial scheduling to billing. This sort of real-time feedback can greatly reduce billing problems. Using this process even more, there is one or more vendor of practice management software that integrates automatic electronic eligibility to the practice management workflow.
A common problem for most providers is unknowingly providing services which are not “authorized” by the payer. Even if authorization is given, it could be lost from the payer and denied as unauthorized until proof is given. Researching the problem and giving proof to the carrier costs you money. 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 the network.
The HIPAA referral request and authorization process allows providers to automate the requests and logging of authorization for a lot of services. Using this electronic record of authorization, you will have the documentation you need in the event you will find questions on the timeliness of requests or actual approval of services. An extra advantage of this automated precertification is a decrease in time and labor typically spent getting authorization via telephone or fax. With electronic authorization, your employees may have more hours 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 at first 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 seek the assistance of a medical management vendor for support using this labor-intensive process.
Submitting claims electronically is regarded as the fundamental process from the five HIPPA tools. By processing your claims electronically you get priority processing. Your electronically submitted claims go directly 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 cost of claims processing and streamlines internal processes enabling you to give attention to 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 decrease in insurance reimbursement time results in a significant rise in cash available for the requirements a developing 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 every rebill processed from the payer – causing more be right for you and also the carrier. Making use of the HIPAA electronic claim status standard offers an alternative choice to paying your staff to enjoy hours on the phone checking claim status. As well as confirming claim receipt, you may also get details on the payment processing status. The decline in denials lets your staff give attention to more productive revenue recovery activities. You can utilize claim status information to your benefit by optimizing the timing of your claim inquiries. For example, once you know that electronic remittance advice and payment are received within 21 days coming from a specific payer, you are able to setup a brand new claim inquiry process on day 22 for all claims because batch which can be still not posted.
HIPAA’s electronic remittance advice process can provide extremely valuable information for your practice. It can much not only save your staff effort and time. It improves the timeliness and accuracy of postings. Decreasing the time between payment and posting greatly reduces the occurrence of rebilling of open accounts – a major reason for denials.
Another major reap the benefits of electronic remittance advice is the fact that all adjustments are posted. Without this timely information, you data entry personnel may forget to post the “zero dollar payments,” causing an overly inflated A/R. This distortion also can make it more challenging for you to identify denial patterns using the carriers. You can even take a proactive approach with the remittance advice data and begin a denial database to zero in on problem codes and problem carriers.
Due to HIPAA, virtually all major commercial carriers now provide free access to these electronic processes via their websites. Using a simple Web connection, you can register at these websites and have real-time usage of patient insurance information that was previously available only by telephone. Even smallest practice should think about registering to confirm eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and enhance your provider profile. Registration time as well as the educational curve are minimal.
Registering free of charge access to individual carrier websites could be a significant improvement over paper for the practice. The drawback for this approach that the staff must continually log inside and out of multiple websites. A far more unified approach is to apply a sensible practice management application which includes full support for electronic data exchange with all the carriers. Depending on the type of software you use, your alternatives and expenses may vary regarding how you submit claims. Medicare provides the choice to submit claims at no cost directly via dial-up connection.
Alternately, you may have the choice 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 price is generally determined on a per-claim basis and can usually be negotiated, with prices starting around twenty-four cents per claim. When using billing software along with a clearinghouse is an excellent method to streamline procedures and maximize collections, it is important ejbexv closely monitor the performance of your own clearinghouse. Providers should instruct their staff to file claims at least 3 x each week and verify receipt of those claims by reviewing the various reports offered by the clearinghouses.
These systems automatically review electronic claims before these are sent. They search 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 for you to correct the claim before it is submitted, making it much less likely the claim will likely be denied then must be resubmitted. Remember, the carriers earn money the more time they can hold to your instalments. A good claim scrubber can help including the playing field. All carriers use their own version of the claim scrubber whenever they receive claims from you.
With the mandates from Medicare with other carriers following suit, you simply cannot afford to never go electronic. Every aspect of your own practice can be enhanced through the HIPAA standards of electronic data exchange. While the initial investment in hardware, software and training might cost tens of thousands of dollars, the correct use of the technology virtually guarantees a fast return on your investment.