Just like the major finance institutions closely following the lead of the Federal Reserve, medical health insurance carriers adhere 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. How about the commercial carriers? If you are not fully utilizing all the electronic options at your disposal, you might be losing money. In this article, I will discuss five key electronic business processes that all major payers must support and how you can use them to dramatically boost 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 carry on and submit a very high volume of paper claims will receive a Medicare “request for documentation,” which should be completed within 45 days to confirm their eligibility to submit paper claims. Denials are not susceptible to appeal. In essence that if you are not filing claims electronically, it will cost you more time, money and hassles.
While we have seen much groaning and distress over new regulations heaved upon us by HIPAA (the medical 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 carriers and providers. These new standards usher in a new era for providers by offering five ways to optimize the claims process.
Practitioners frequently accept insurance cards that are invalid, expired, or even faked. The Health Insurance Association of America (HIAA) found in a 2003 study that 14 percent of claims were denied. From that percentage, a full 25 % resulted from eligibility issues. Specifically, 22 percent resulted from coverage termination and/or coverage lapses. Eligibility denials not just create more work by means of research and rebilling, but they also increase the chance of nonpayment. Poor eligibility verification raises the probability of failing to precertify using 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.
Utilization of the medical check eligibility allows practitioners to automate this method, increasing the number of patients and procedures which can be correctly verified. This standard lets you 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. Using this process even further, there is one or more 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 that are not “authorized” by the payer. Even when authorization is provided, it could be lost from the payer and denied as unauthorized until proof is offered. Researching the issue and giving proof to the carrier costs you money. The circumstance is much 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. With this particular electronic record of authorization, you will have the documentation you require just in case there are questions about the timeliness of requests or actual approval of services. An extra benefit of this automated precertification is a decrease in some time and labor typically spent getting authorization via telephone or fax. With electronic authorization, your staff may have more time to get additional procedures authorized and can never have trouble getting to a payer representative. Additionally, your employees will more effectively identify out-of-network patients at first and have a possiblity 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 find the assistance of a medical management vendor for support with 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 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 cashflow, reduces the cost of claims processing and streamlines internal processes letting you focus 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 rise in cash designed for the needs of a developing practice. Reduced labor, office supplies and postage all contribute to the bottom line of the practice when submitting claims electronically.
Continuous rebilling of unpaid claims creates denials for duplicate claims with every rebill processed from the payer – causing more meet your needs as well as the carrier. Making use of the HIPAA electronic claim status standard offers an alternative choice to paying your employees to invest 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 employees concentrate on more productive revenue recovery activities. You can use claim status information to your advantage by optimizing the timing of your own claim inquiries. For instance, once you learn that electronic remittance advice and payment are received within 21 days from the specific payer, you are able to create a whole new claim inquiry process on day 22 for many claims in this batch which are still not posted.
HIPAA’s electronic remittance advice process can provide extremely valuable information for your practice. It does much more than simply save your valuable staff time and energy. It increases the timeliness and accuracy of postings. Reducing the time between payment and posting greatly reduces the occurrence of rebilling of open accounts – a major reason behind denials.
Another major reap the benefits 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 excessively inflated A/R. This distortion also can make it harder for you to identify denial patterns with the carriers. You can even require a proactive approach with all the remittance advice data and start 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. Using a simple Internet connection, you are able to register at these websites and possess real-time use of patient insurance information that was previously available only by telephone. Even the smallest practice should consider registering to ensure eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and improve your provider profile. Registration some time and the educational curve are minimal.
Registering free of charge use of individual carrier websites could be a significant improvement over paper to your practice. The drawback for this approach is that your staff must continually log out and in of multiple websites. A much more unified approach is by using a sensible practice management application which includes full support for electronic data exchange with the carriers. Depending on the form of software you utilize, your options and costs can vary as to the way you submit claims. Medicare provides the choice to submit claims at no cost directly via dial-up connection.
Alternately, you could have the option to employ a clearinghouse that receives your claims for Medicare along with other carriers and submits them for you personally. Many software vendors dictate the clearinghouse you need to use to submit claims. The price is normally determined on the per-claim basis and can usually be negotiated, with prices starting around twenty-four cents per claim. When using billing software as well as a clearinghouse is an efficient method to streamline procedures and maximize collections, it is important ejbexv closely monitor the performance of the clearinghouse. Providers should instruct their staff to file claims a minimum of three times a week and verify receipt of these claims by reviewing the various reports supplied by the clearinghouses.
These systems automatically review electronic claims before these are sent out. 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 look at your RVU sequencing to ensure maximum reimbursement.
This method affords the staff time and energy to correct the claim before it is actually submitted, making it much less likely the claim will be denied then have to be resubmitted. Remember, the carriers earn money the more they can hold to your instalments. A great claim scrubber can help even the playing field. All carriers use their particular version of any claim scrubber once they receive claims from you.
With the mandates from Medicare along with all the other carriers following suit, you simply cannot afford not to go electronic. All aspects of your own practice could be enhanced by the use of the HIPAA standards of electronic data exchange. As the initial investment in hardware, software and training could cost hundreds and hundreds of dollars, the appropriate utilization of the technology virtually guarantees a rapid return on the investment.