Much like the major finance institutions closely following the lead of the Federal Reserve, medical health insurance carriers follow the lead of Medicare. Medicare is getting serious about filing medical claims electronically. Yes, avoiding hassles from Medicare is only one part of the puzzle. What about the commercial carriers? In case you are not fully utilizing all of the electronic options at your disposal, you might be losing money. In the following paragraphs, 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 possibilities for going electronic.
Medicare recently began putting some pressure on providers to start filing electronically. Physicians who still submit a very high volume of paper claims will get a Medicare “request for documentation,” which must be completed within 45 days to confirm their eligibility to submit paper claims. Denials usually are not subjected to appeal. In essence that if you are not filing claims electronically, it will cost you additional time, money and hassles.
While there has been much groaning and distress over new regulations heaved upon us by HIPAA (the 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 companies 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 that are 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. From that percentage, a full 25 percent resulted from eligibility issues. Specifically, 22 percent resulted from coverage termination and coverage lapses. Eligibility denials not just create more work in the form of research and rebilling, in addition they increase the chance of nonpayment. Poor eligibility verification increases the chance of neglecting to precertify with the correct carrier, which may then result in a clinical denial. Furthermore, time wasted as a result of incorrect eligibility verification can lead you to miss the carrier’s timely filing requirements.
Utilisation of the eligibility verification system allows practitioners to automate this method, increasing the amount of patients and operations which can be correctly verified. This standard allows you to query eligibility several times through 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 exists at least one vendor of practice management software that integrates automatic electronic eligibility in to the practice management workflow.
A standard problem for many providers is unknowingly providing services that are not “authorized” from the payer. Even though authorization is provided, it could be lost from the payer and denied as unauthorized until proof is offered. Researching the matter and giving proof to the carrier costs you cash. The situation is much more acute with HMOs. Without proper referral authorization, you risk providing free services by performing work that is away from 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 will have the documentation you will need in the event you will find questions on the timeliness of requests or actual approval of services. Yet another benefit from this automated precertification is a decrease in time and labor typically spent getting authorization via telephone or fax. With electronic authorization, your staff could have more hours to get more procedures authorized and definately will never have trouble arriving at a payer representative. Additionally, your employees will better identify out-of-network patients in the beginning and 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 get the assistance of a medical management vendor for support with this labor-intensive process.
Submitting claims electronically is regarded as the fundamental process out of the five HIPPA tools. By processing your claims electronically you obtain 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 letting you concentrate on patient care. A paper insurance claim typically 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 boost in cash readily available for the requirements of a growing practice. Reduced labor, office supplies and postage all play a role in the conclusion of your practice when submitting claims electronically.
Continuous rebilling of unpaid claims creates denials for duplicate claims with each rebill processed through the payer – causing more be right for you and the carrier. Utilizing the HIPAA electronic claim status standard offers an alternative to paying your staff to invest hours on the phone checking claim status. In addition to confirming claim receipt, you can also get details on the payment processing status. The reduction in denials lets your staff focus on more productive revenue recovery activities. You can utilize claim status information to your benefit by optimizing the timing of your claim inquiries. As an example, if you know that electronic remittance advice and payment are received within 21 days coming from a specific payer, it is possible to setup a new claim inquiry process on day 22 for many claims because batch that 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 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 take advantage 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 makes it harder for you to identify denial patterns using the carriers. You can 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.
Due to HIPAA, virtually all major commercial carriers now provide free access to these electronic processes via their websites. Having a simple Web connection, you can register at websites like these and have real-time use of patient insurance information that was once available only by telephone. Including the smallest practice should think about registering to verify eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and update your provider profile. Registration some time and the educational curve are minimal.
Registering at no cost access to individual carrier websites can be quite a significant improvement over paper for the practice. The drawback for this approach is that your staff must continually log inside and out of multiple websites. A much more unified approach is to use a good practice management application that includes full support for electronic data exchange using the carriers. Depending on the form of software you use, your options and costs may vary concerning how you will submit claims. Medicare offers the solution to submit claims at no cost directly via dial-up connection.
Alternately, you could have the option to utilize 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 have to use to submit claims. The cost is usually determined on the per-claim basis and will usually be negotiated, with prices starting around twenty-four cents per claim. When using billing software and a clearinghouse is an effective 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 a minimum of 3 x per week and verify receipt of the claims by reviewing the many reports supplied by the clearinghouses.
These systems automatically review electronic claims before they are sent out. They search for missing fields, misused modifiers, mismatched CPT and ICD-9 codes and generate a report of errors and omissions. The best systems will also check your RVU sequencing to ensure maximum reimbursement.
This process gives the staff time and energy to correct the claim before it is actually submitted, rendering it much less likely that the claim will be denied then need to be resubmitted. Remember, the carriers earn money the longer they can hold to your instalments. A good claim scrubber can help even the playing field. All carriers use their particular version of the claim scrubber whenever they receive claims on your part.
With all the mandates from Medicare and with other carriers following suit, you just cannot afford to not go electronic. All facets of the 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 correct utilisation of the technology virtually guarantees a fast return on the investment.