Just like the major financial institutions closely pursuing the lead of the Federal Reserve, medical health insurance carriers follow the lead of Medicare. Medicare is getting interested in filing medical claims electronically. Yes, avoiding hassles from Medicare is just one piece of the puzzle. Have you thought about the commercial carriers? If you are not fully utilizing all the electronic options at your disposal, you are losing money. In this post, I am going to discuss five key electronic business processes that all major payers must support and exactly how you can use them to dramatically enhance your bottom line. We’ll also explore available options for going electronic.
Medicare recently began putting some pressure on providers to begin filing electronically. Physicians who still submit a high volume 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. The bottom line is that should you be not filing claims electronically, it will set you back extra time, money and hassles.
While there has been much groaning and distress over new regulations and rules heaved upon us by HIPAA (the medical Insurance Portability and Accountability Act of 1996), there exists 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 ways to optimize the claims process.
Practitioners frequently accept insurance cards which are invalid, expired, or even faked. The Health Insurance Association of America (HIAA) found in a 2003 study that 14 percent of all the claims were denied. Out of that percentage, a full 25 percent resulted from eligibility issues. Specifically, 22 percent resulted from coverage termination or coverage lapses. Eligibility denials not merely create more work in the form of research and rebilling, they also increase the chance of nonpayment. Poor eligibility verification boosts the chance of failing to precertify with the correct carrier, which might then result in a clinical denial. Furthermore, time wasted because of incorrect eligibility verification can make you miss the carrier’s timely filing requirements.
Use of the verify patient insurance eligibility allows practitioners to automate this method, increasing the amount of patients and procedures which are correctly verified. This standard allows you to query eligibility multiple times through the patient’s care, from initial scheduling to billing. This kind of real-time feedback can help reduce billing problems. Using this process even more, there is certainly at least one vendor of practice management software that integrates automatic electronic eligibility in to the practice management workflow.
A common problem for many providers is unknowingly providing services which are not “authorized” through the payer. Even though authorization is offered, it may be lost through the payer and denied as unauthorized until proof is offered. Researching the issue and giving proof for the carrier costs serious cash. The problem is even more acute with HMOs. Without proper 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. With this electronic record of authorization, you will have the documentation you require just in case you can find questions about the timeliness of requests or actual approval of services. An extra 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 obtain more procedures authorized and definately will never have trouble getting to a payer representative. Additionally, your employees will more efficiently 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 usually are not yet fully implemented by all payers. It is a good idea 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 from the five HIPPA tools. By processing your claims electronically you obtain 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 cost of claims processing and streamlines internal processes letting you focus on patient care. A paper insurance claim typically 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 boost in cash readily available for the requirements a growing 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 by the payer – causing more be right for you as well as the carrier. Making use of the HIPAA electronic claim status standard offers an alternative to paying your staff to spend hours on the phone checking claim status. Along with confirming claim receipt, you may also get details on the payment processing status. The reduction in denials lets your staff give attention to more productive revenue recovery activities. You may use claim status information in your favor by optimizing the timing of the claim inquiries. As an example, once you know that electronic remittance advice and payment are received within 21 days from a specific payer, it is possible to create a brand new claim inquiry process on day 22 for all claims in this batch that are still not posted.
HIPAA’s electronic remittance advice process can offer extremely valuable information to your practice. It will much more than simply keep your staff time and energy. It increases the timeliness and accuracy of postings. Lowering the time between payment and posting greatly reduces the appearance of rebilling of open accounts – an important reason for denials.
Another major reap the benefits of electronic remittance advice is the fact all adjustments are posted. Without it timely information, you data entry personnel may neglect to post the “zero dollar payments,” resulting in an excessively inflated A/R. This distortion also can make it more difficult for you to identify denial patterns using the carriers. You may also take a proactive approach with the remittance advice data and begin a denial database to zero in on problem codes and problem carriers.
Thanks to HIPAA, almost all major commercial carriers now provide free usage of these electronic processes via their websites. With a simple Web connection, you can register at these web sites and also have real-time use of patient insurance information that used to be available only by phone. Even smallest practice should think about registering to ensure eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and update your provider profile. Registration time and the learning curve are minimal.
Registering for free access to individual carrier websites can be quite a significant improvement over paper to your practice. The drawback to this particular approach is your staff must continually log inside and out of multiple websites. A far more unified approach is by using a good practice management application that includes full support for electronic data exchange with all the carriers. Depending on the type of software you make use of, your alternatives and expenses can vary greatly concerning how you submit claims. Medicare supplies the choice to submit claims free of charge directly via dial-up connection.
Alternately, you may have an opportunity to employ a clearinghouse that receives your claims for Medicare along with other carriers and submits them for you. Many software vendors dictate the clearinghouse you have to use to submit claims. The cost is generally determined over a per-claim basis and may usually be negotiated, with prices starting around twenty-four cents per claim. While using the billing software as well as a clearinghouse is an effective way to streamline procedures and maximize collections, it is important ejbexv closely monitor the performance of your own clearinghouse. Providers should instruct their staff to submit 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 they may be sent. They check 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 check your RVU sequencing to make certain maximum reimbursement.
This procedure affords the staff time and energy to correct the claim before it is submitted, making it much less likely that the claim is going to be denied and after that have to be resubmitted. Remember, the carriers earn money the longer they are able to hold onto your instalments. A great claim scrubber will help even playing field. All carriers use their own version of the claim scrubber whenever they receive claims from you.
With the mandates from Medicare along with other carriers following suit, you simply do not want to never go electronic. Every aspect of your practice could be enhanced through the HIPAA standards of electronic data exchange. Whilst the initial investment in hardware, software and training could cost hundreds and hundreds of dollars, the proper use of the technology virtually guarantees a rapid return on the investment.
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