Similar to the major finance institutions closely following the lead of the Federal Reserve, medical insurance carriers follow the lead of Medicare. Medicare is getting seriously interested in filing medical claims electronically. Yes, avoiding hassles from Medicare is just one part of the puzzle. How about the commercial carriers? Should you be not fully utilizing all 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 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 higher volume of paper claims will get a Medicare “request for documentation,” which has to be completed within 45 days to confirm their eligibility to submit paper claims. Denials usually are not susceptible to appeal. In essence that in case 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 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 providing five methods to optimize the claims process.
Practitioners frequently accept insurance cards that are invalid, expired, or perhaps faked. The Medical Insurance Association of America (HIAA) found in a 2003 study that 14 percent of claims were denied. Away from that percentage, a complete 25 % 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 risk of nonpayment. Poor eligibility verification boosts the likelihood of neglecting to precertify with the correct carrier, which can 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.
Use of the medi cal eligibility check allows practitioners to automate this method, increasing the quantity of patients and operations which can be correctly verified. This standard enables you to query eligibility many times through 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 exists at least one vendor of practice management software that integrates automatic electronic eligibility in to the practice management workflow.
A common problem for a lot of providers is unknowingly providing services that are not “authorized” by the payer. Even when authorization is provided, it may be lost through the payer and denied as unauthorized until proof is provided. Researching the issue and giving proof to the carrier costs serious cash. The situation is a lot 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 most services. With this particular electronic record of authorization, you will find the documentation you require just in case there are questions regarding 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 will have more time to get additional procedures authorized and definately will never have trouble reaching a payer representative. Additionally, your employees will more effectively identify out-of-network patients in the beginning and also a chance to request an exception. While extremely useful, electronic referral requests and authorizations usually are not yet fully implemented by all payers. It may be beneficial to find the help of a medical management vendor for support with this particular labor-intensive process.
Submitting claims electronically is regarded as the fundamental process out 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 expense of 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, in which the average payment time for electronic claims is 14 days. The reduction in insurance reimbursement time results in a significant increase in cash readily available for the requirements a developing practice. Reduced labor, office supplies and postage all bring about 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 through the payer – causing more meet your needs and the carrier. Using 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 decline in denials lets your employees concentrate on more productive revenue recovery activities. You may use claim status information to your benefit by optimizing the timing of your claim inquiries. For example, once you learn that electronic remittance advice and payment are received within 21 days from the specific payer, you can create a whole new claim inquiry process on day 22 for those claims in that batch that are still not posted.
HIPAA’s electronic remittance advice process can offer extremely valuable information in your practice. It can much more than just keep your staff effort and time. It improves the timeliness and accuracy of postings. Lowering the time between payment and posting greatly reduces the occurrence of rebilling of open accounts – an important reason for denials.
Another major benefit from electronic remittance advice is the fact all adjustments are posted. Without this timely information, you data entry personnel may fail to post the “zero dollar payments,” causing an overly inflated A/R. This distortion also can make it more difficult that you should identify denial patterns with the carriers. You may also require 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, almost all major commercial carriers now provide free use 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 once available only by telephone. Even the smallest practice should look into registering to ensure eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and improve your provider profile. Registration time as well as the learning curve are minimal.
Registering free of charge usage of individual carrier websites can be quite a significant improvement over paper to your practice. The drawback to this particular approach that the staff must continually log inside and out of multiple websites. A much more unified approach is by using a sensible practice management application that includes full support for electronic data exchange using the carriers. Depending on the type of software you make use of, your options and expenses can vary as to how you submit claims. Medicare provides the choice to submit claims free of charge directly via dial-up connection.
Alternately, you might have an opportunity to use 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 must use to submit claims. The cost is generally determined on a per-claim basis and will usually be negotiated, with prices starting around twenty-four cents per claim. When using billing software as well as a clearinghouse is an excellent approach to streamline procedures and maximize collections, it is crucial ejbexv closely monitor the performance of your clearinghouse. Providers should instruct their staff to submit claims a minimum of 3 x a week and verify receipt of the claims by reviewing the various reports offered by the clearinghouses.
These systems automatically review electronic claims before they 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 best systems will also examine your RVU sequencing to make certain maximum reimbursement.
This method provides the staff time to correct the claim before it really is submitted, making it far less likely the claim will likely be denied and after that need to be resubmitted. Remember, the carriers make money the more time they are able to hold on to your payments. An excellent claim scrubber may help including the playing field. All carriers use their particular version of any claim scrubber once they receive claims on your part.
Using the mandates from Medicare with other carriers following suit, you just do not want to never go electronic. All facets of your own practice may be enhanced using the HIPAA standards of electronic data exchange. While the initial investment in hardware, software and training could cost tens of thousands of dollars, the correct use of the technology virtually guarantees a fast return on your own investment.