Similar to the major finance institutions closely following the lead of the Federal Reserve, medical insurance carriers adhere to the lead of Medicare. Medicare is becoming serious about filing medical claims electronically. Yes, avoiding hassles from Medicare is just one part of the puzzle. What about the commercial carriers? Should you be not fully utilizing all of the electronic options at your disposal, you are losing money. In the following paragraphs, I will discuss five key electronic business processes that all major payers must support and how they are utilized to dramatically enhance your bottom line. We’ll also explore possibilities for going electronic.
Medicare recently began putting some pressure on providers to begin filing electronically. Physicians who continue to 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 are not subject to appeal. In essence that should you be not filing claims electronically, it will set you back more time, money and hassles.
While there has been much groaning and distress over new rules and 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 first 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 methods to optimize the claims process.
Practitioners frequently accept insurance cards which are invalid, expired, or perhaps faked. The Medical Insurance Association of America (HIAA) found in a 2003 study that 14 percent of all claims were denied. Away from that percentage, an entire 25 percent resulted from eligibility issues. More specifically, 22 percent resulted from coverage termination or coverage lapses. Eligibility denials not just create more work by means of research and rebilling, they also increase the potential risk of nonpayment. Poor eligibility verification increases the chance of failing to precertify using the correct carrier, which can then result in a clinical denial. Furthermore, time wasted because of incorrect eligibility verification can make you miss the carrier’s timely filing requirements.
Utilization of the verify medical eligibility allows practitioners to automate this process, increasing the number of patients and operations that are correctly verified. This standard lets you query eligibility many times during the patient’s care, from initial scheduling to billing. This kind of real-time feedback can greatly reduce billing problems. Using this process even more, there is certainly a minumum of one vendor of practice management software that integrates automatic electronic eligibility to the practice management workflow.
A typical problem for many providers is unknowingly providing services which are not “authorized” through the payer. Even though authorization is given, it may be lost from the payer and denied as unauthorized until proof is provided. Researching the problem and giving proof towards the carrier costs serious cash. The circumstance is much more acute with HMOs. Without proper 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 many services. Using this electronic record of authorization, you have the documentation you require in case you can find questions on the timeliness of requests or actual approval of services. An additional benefit from this automated precertification is a reduction in some time and labor typically spent getting authorization via telephone or fax. With electronic authorization, your employees could have additional time to get more procedures authorized and will never have trouble reaching a payer representative. Additionally, your employees will more efficiently identify out-of-network patients at first and have a opportunity to request an exception. While extremely useful, electronic referral requests and authorizations are not yet fully implemented by all payers. It may be beneficial to seek the assistance of a medical management vendor for support with this labor-intensive process.
Submitting claims electronically is easily the most fundamental process from the five HIPPA tools. By processing your claims electronically you get 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 fee for claims processing and streamlines internal processes allowing you to give attention to patient care. A paper insurance claim normally takes about 45 days for reimbursement, where average payment time for electronic claims is 14 days. The reduction in insurance reimbursement time results in a significant rise in cash available for the requirements a growing practice. Reduced labor, office supplies and postage all contribute to the bottom line of your practice when submitting claims electronically.
Continuous rebilling of unpaid claims creates denials for duplicate claims with each rebill processed from the payer – causing more work for you and also the carrier. Making use of the HIPAA electronic claim status standard offers a substitute for paying your staff to spend hours on the phone checking claim status. In addition to confirming claim receipt, you can even get details on the payment processing status. The decrease in denials lets your employees focus on more productive revenue recovery activities. You can use claim status information to your advantage by optimizing the timing of your own claim inquiries. As an example, if you know that electronic remittance advice and payment are received within 21 days from the specific payer, you can set up a new claim inquiry process on day 22 for those claims in that batch which are still not posted.
HIPAA’s electronic remittance advice process can provide extremely valuable information in your practice. It will much more than just save 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 – a significant reason for 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,” leading to an overly inflated A/R. This distortion also causes it to be harder for you to identify denial patterns with all the carriers. You may also take 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 access to these electronic processes via their websites. With a simple Internet connection, it is possible to register at these websites and have real-time access to patient insurance information that was once available only by phone. Including the smallest practice should consider registering to ensure eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and enhance your provider profile. Registration some time and the learning curve are minimal.
Registering free of charge usage of individual carrier websites can be quite a significant improvement over paper for the practice. The drawback to this particular approach that the staff must continually log in and out of multiple websites. A more unified approach is to use a sensible practice management application that also includes full support for electronic data exchange using the carriers. Depending on the kind of software you use, your alternatives and expenses may vary concerning how you will submit claims. Medicare provides the solution to submit claims at no cost directly via dial-up connection.
Alternately, you might have the choice to utilize a clearinghouse that receives your claims for Medicare as well as other carriers and submits them for you personally. Many software vendors dictate the clearinghouse you must use to submit claims. The cost is normally determined on a per-claim basis and may usually be negotiated, with prices starting around twenty-four cents per claim. While using the billing software and a clearinghouse is an efficient 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 each week and verify receipt of the claims by reviewing the different reports offered by the clearinghouses.
These systems automatically review electronic claims before they may be sent out. 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 check your RVU sequencing to make certain maximum reimbursement.
This procedure provides the staff time for you to correct the claim before it is actually submitted, making it much less likely that this claim will be denied then have to be resubmitted. Remember, the carriers generate income the more they could hold onto your instalments. A great claim scrubber can help even the playing field. All carriers use their own version of any claim scrubber when they receive claims on your part.
Using the mandates from Medicare along with other carriers following suit, you just do not want not to go electronic. Every aspect of your own practice could be enhanced through the HIPAA standards of electronic data exchange. As the initial investment in hardware, software and training might cost hundreds and hundreds of dollars, the correct utilisation of the technology virtually guarantees a fast return on your own investment.