Similar to the major financial institutions closely pursuing the lead of the Federal Reserve, medical health insurance carriers follow 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? If you are not fully utilizing each of the electronic options at your disposal, you are losing money. In the following paragraphs, 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 continue to submit a very high amount of paper claims will receive a Medicare “request for documentation,” which must be completed within 45 days to ensure their eligibility to submit paper claims. Denials are certainly not subject to appeal. The end result is that if 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 rules and regulations heaved upon us by HIPAA (the Insurance Portability and Accountability Act of 1996), there exists a silver lining. With HIPAA, Congress mandated the initial electronic data standards for routine business processes between insurance companies and providers. These new standards usher in a new era for providers by providing five approaches to optimize the claims process.
Practitioners frequently accept insurance cards which can be 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 full 25 % resulted from eligibility issues. Specifically, 22 percent resulted from coverage termination and coverage lapses. Eligibility denials not merely create more work as research and rebilling, they also increase the potential risk of nonpayment. Poor eligibility verification increases the chance of neglecting to precertify with all the correct carrier, which can 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 insurance eligibility allows practitioners to automate this process, increasing the number of patients and operations which are correctly verified. This standard allows 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 more, there is certainly at least one vendor of practice management software that integrates automatic electronic eligibility into the practice management workflow.
A typical problem for many providers is unknowingly providing services which are not “authorized” by the payer. Even when authorization is offered, it may be lost by the payer and denied as unauthorized until proof is provided. Researching the issue and giving proof for 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 which is outside of the network.
The HIPAA referral request and authorization process allows providers to automate the requests and logging of authorization for a lot of services. With this particular electronic record of authorization, you will find the documentation you will need in the event you can find questions about the timeliness of requests or actual approval of services. Yet another 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 staff may have additional time to get additional procedures authorized and definately will never have trouble reaching a payer representative. Additionally, your staff will better identify out-of-network patients in the beginning 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 using this labor-intensive process.
Submitting claims electronically is the most fundamental process out from the five HIPPA tools. By processing your claims electronically you obtain 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 enabling you to concentrate on patient care. A paper insurance claim typically takes about 45 days for reimbursement, in which the average payment time for electronic claims is 14 days. The decrease in insurance reimbursement time results in a significant increase in cash designed for the requirements an increasing 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 from the payer – causing more work for you and the carrier. Using the HIPAA electronic claim status standard offers an alternative to paying your staff to enjoy hours on the phone checking claim status. Along with confirming claim receipt, you can 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 to your benefit by optimizing the timing of the claim inquiries. As an example, once you learn that electronic remittance advice and payment are received within 21 days coming from a specific payer, you can setup a new claim inquiry process on day 22 for those claims because batch that are still not posted.
HIPAA’s electronic remittance advice process provides extremely valuable information for your practice. It can much more than just save your valuable staff time and energy. It increases the timeliness and accuracy of postings. Lowering the time between payment and posting greatly reduces the occurrence of rebilling of open accounts – a significant reason behind denials.
Another major take advantage of electronic remittance advice is the fact all adjustments are posted. Without it timely information, you data entry personnel may forget to post the “zero dollar payments,” causing an excessively inflated A/R. This distortion also causes it to be more challenging for you to identify denial patterns with all the carriers. You can also 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, nearly all major commercial carriers now provide free access to these electronic processes via their websites. With a simple Internet access, you are able to register at websites like these and have real-time access to patient insurance information that used to be available only by phone. Even the smallest practice should think about registering to confirm eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and update your provider profile. Registration time and the training curve are minimal.
Registering at no cost access to individual carrier websites can be a significant improvement over paper for the practice. The drawback for this approach is that your staff must continually log out and in of multiple websites. A far more unified approach is to use a sensible practice management application which includes full support for electronic data exchange with the carriers. Depending on the kind of software you utilize, your options and expenses can vary greatly regarding how you submit claims. Medicare offers the choice to submit claims free of charge directly via dial-up connection.
Alternately, you might have the choice to employ a clearinghouse that receives your claims for Medicare along with 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 over a 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 clearinghouse. Providers should instruct their staff to submit claims a minimum of three times each week and verify receipt of these claims by reviewing the different reports provided 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 very best systems may also examine your RVU sequencing to make certain maximum reimbursement.
This process provides the staff time and energy to correct the claim before it is actually submitted, which makes it far less likely that this claim will be denied and then must be resubmitted. Remember, the carriers earn money the longer they can hold on to your payments. A great claim scrubber can help including the playing field. All carriers use their very own version of the claim scrubber when they receive claims on your part.
With all the mandates from Medicare and with all other carriers following suit, you merely cannot afford not to go electronic. Every aspect of your practice could be enhanced using the HIPAA standards of electronic data exchange. As the initial investment in hardware, software and training could cost tens of thousands of dollars, the proper use of the technology virtually guarantees a rapid return on your investment.