Much like the major financial institutions closely pursuing the lead of the Federal Reserve, medical health 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 part of the puzzle. Have you thought about the commercial carriers? Should you be not fully utilizing all of the electronic options at your disposal, you might be losing money. In this article, 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 improve your bottom line. We’ll also explore available options for going electronic.
Medicare recently began putting some pressure on providers to start filing electronically. Physicians who continue to submit a higher amount of paper claims will receive a Medicare “ask for documentation,” which should be completed within 45 days to verify their eligibility to submit paper claims. Denials are not susceptible to appeal. The end result is that in case you are not filing claims electronically, it can cost you more 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 is 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 approaches to optimize the claims process.
Practitioners frequently accept insurance cards that are invalid, expired, or perhaps faked. The Insurance Association of America (HIAA) found in a 2003 study that 14 percent of claims were denied. From that percentage, a complete 25 % resulted from eligibility issues. Specifically, 22 percent resulted from coverage termination and coverage lapses. Eligibility denials not only create more work as research and rebilling, in addition they increase the potential risk of nonpayment. Poor eligibility verification increases the chance of failing to precertify using the correct carrier, which may 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.
Utilisation of the check medical eligibility allows practitioners to automate this process, increasing the number of patients and operations which are 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 help reduce billing problems. Taking this process even further, there exists at least one vendor of practice management software that integrates automatic electronic eligibility in to the practice management workflow.
A common problem for most providers is unknowingly providing services which are not “authorized” through the payer. Even though authorization is offered, it might be lost by the payer and denied as unauthorized until proof is given. Researching the problem and giving proof for the carrier costs you money. The situation is a lot more acute with HMOs. Without the proper referral authorization, you risk providing free services by performing work which is outside of the network.
The HIPAA referral request and authorization process allows providers to automate the requests and logging of authorization for most services. Using this electronic record of authorization, you will have the documentation you require in case you will find questions on the timeliness of requests or actual approval of services. An additional benefit of this automated precertification is a reduction 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 never have trouble arriving at a payer representative. Additionally, your staff will better identify out-of-network patients in the beginning and 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 may be beneficial to seek the help of a medical management vendor for support with this particular labor-intensive process.
Submitting claims electronically is regarded as the fundamental process 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 income, reduces the expense of claims processing and streamlines internal processes allowing you to give attention to patient care. A paper insurance claim often 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 increase in cash readily available for the needs of a growing practice. Reduced labor, office supplies and postage all contribute to the important thing 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 meet your needs as well as the carrier. Using the HIPAA electronic claim status standard offers a substitute for 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 reduction in denials lets your employees concentrate on more productive revenue recovery activities. You can 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, it is possible to setup a new claim inquiry process on day 22 for all claims in that batch that are still not posted.
HIPAA’s electronic remittance advice process can offer extremely valuable information to your practice. It will much not only save your staff time and effort. It increases the timeliness and accuracy of postings. Reducing the time between payment and posting greatly reduces the appearance of rebilling of open accounts – a significant cause of denials.
Another major take advantage of electronic remittance advice is that all adjustments are posted. Without this timely information, you data entry personnel may fail to post the “zero dollar payments,” leading to an overly inflated A/R. This distortion also causes it to be more difficult so that you can identify denial patterns using the carriers. You can even have a proactive approach with the remittance advice data and commence a denial database to zero in on problem codes and problem carriers.
Thanks to HIPAA, virtually all major commercial carriers now provide free usage of these electronic processes via their websites. Having a simple Internet access, you can register at these websites and have real-time use of patient insurance information that was previously available only by phone. Including the smallest practice should look into registering to confirm 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 free of charge usage of individual carrier websites can be a significant improvement over paper for the practice. The drawback to this approach is your staff must continually log in and out of multiple websites. A more unified approach is to use a sensible practice management application that includes full support for electronic data exchange using the carriers. Depending on the form of software you make use of, your alternatives and costs can vary greatly as to how you submit claims. Medicare supplies the option to submit claims at no cost directly via dial-up connection.
Alternately, you might have the option 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 need to use to submit claims. The cost 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 along with a clearinghouse is an effective method to streamline procedures and maximize collections, it is important ejbexv closely monitor the performance of your clearinghouse. Providers should instruct their staff to submit claims at least 3 x a week and verify receipt of the claims by reviewing the different reports supplied by the clearinghouses.
These systems automatically review electronic claims before they may be sent. They look for missing fields, misused modifiers, mismatched CPT and ICD-9 codes and produce a report of errors and omissions. The best systems may also examine your RVU sequencing to make sure maximum reimbursement.
This process affords the staff time for you to correct the claim before it really is submitted, rendering it less likely that this claim is going to be denied then have to be resubmitted. Remember, the carriers generate income the more time they could hold on to your payments. An excellent claim scrubber can help even playing field. All carriers use their very own version of any claim scrubber when they receive claims on your part.
Using the mandates from Medicare with other carriers following suit, you merely cannot afford to never go electronic. Every aspect of your practice could be enhanced using the HIPAA standards of electronic data exchange. While the initial investment in hardware, software and training might cost hundreds and hundreds of dollars, the proper utilisation of the technology virtually guarantees a fast return on your own investment.