Much like the major finance institutions closely following the lead of the Federal Reserve, medical insurance carriers adhere to the lead of Medicare. Medicare is becoming seriously interested in filing medical claims electronically. Yes, avoiding hassles from Medicare is just one piece of the puzzle. Have you thought about the commercial carriers? In case you are not fully utilizing each 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 just how you can use them to dramatically improve your bottom line. We’ll also explore options available for going electronic.
Medicare recently began putting some pressure on providers to start filing electronically. Physicians who continue to submit a higher level 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 are certainly not subjected to appeal. In essence that should you be not filing claims electronically, it will set you back more time, money and hassles.
While we have seen much groaning and distress over new regulations and rules 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 providing five approaches 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 claims were denied. Away from that percentage, a full 25 % resulted from eligibility issues. Specifically, 22 percent resulted from coverage termination and/or coverage lapses. Eligibility denials not only 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 using the correct carrier, which might 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.
Utilisation of the verify patient insurance eligibility allows practitioners to automate this procedure, increasing the quantity of patients and procedures which can be correctly verified. This standard enables you to query eligibility multiple times through the patient’s care, from initial scheduling to billing. This type of real-time feedback can greatly reduce billing problems. Taking this process even further, there is 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” through the payer. Even when authorization is offered, it could be lost through the payer and denied as unauthorized until proof is offered. Researching the issue and giving proof towards the carrier costs you money. The problem is a lot more acute with HMOs. Without the right referral authorization, you risk providing free services by performing work which 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 will have the documentation you will need in the event you can find questions regarding the timeliness of requests or actual approval of services. An extra benefit of this automated precertification is a decrease in time as well as labor typically spent getting authorization via telephone or fax. With electronic authorization, your staff will have additional time to get additional procedures authorized and will have never trouble reaching a payer representative. Additionally, your staff will more efficiently identify out-of-network patients at first and also a possiblity to request an exception. While extremely useful, electronic referral requests and authorizations are certainly 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 easily the most 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 cash flow, reduces the expense of claims processing and streamlines internal processes enabling you to focus 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 decrease in insurance reimbursement time results in a significant increase in cash designed for the requirements of a growing practice. Reduced labor, office supplies and postage all bring about the important thing of your practice when submitting claims electronically.
Continuous rebilling of unpaid claims creates denials for duplicate claims with every rebill processed from the payer – causing more be right for you and the carrier. Using the HIPAA electronic claim status standard offers an alternative choice to paying your staff to enjoy hours on the phone checking claim status. In addition to confirming claim receipt, you may also get details on the payment processing status. The decline in denials lets your staff give attention to more productive revenue recovery activities. You can use claim status information to your advantage 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 from the specific payer, you can set up a whole new claim inquiry process on day 22 for all claims because batch which can be still not posted.
HIPAA’s electronic remittance advice process can provide extremely valuable information to your practice. It does much more than just save 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 – a major reason for denials.
Another major reap the benefits of electronic remittance advice is 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 more challenging so that you can identify denial patterns with all the carriers. You may also have a proactive approach with all the remittance advice data and start a denial database to zero in on problem codes and problem carriers.
Because of HIPAA, nearly all major commercial carriers now provide free usage of these electronic processes via their websites. Using a simple Internet connection, it is possible to register at websites like these and also have real-time usage of patient insurance information that was previously available only by telephone. Even 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 and the training curve are minimal.
Registering free of charge access to individual carrier websites can be a significant improvement over paper to your practice. The drawback for this approach is your staff must continually log inside and out of multiple websites. A more unified approach is to use a good practice management application that also includes full support for electronic data exchange using the carriers. Depending on the type of software you use, your choices and costs can vary greatly as to the way you submit claims. Medicare supplies the solution to submit claims free of charge directly via dial-up connection.
Alternately, you could have the choice to use a clearinghouse that receives your claims for Medicare and other carriers and submits them for you personally. Many software vendors dictate the clearinghouse you must use to submit claims. The fee is generally determined over a per-claim basis and may usually be negotiated, with prices starting around twenty-four cents per claim. While using the billing software as well as a clearinghouse is an effective approach to streamline procedures and maximize collections, it is necessary ejbexv closely monitor the performance of your own clearinghouse. Providers should instruct their staff to submit claims at the very least 3 x a week and verify receipt of those claims by reviewing the many 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 produce a report of errors and omissions. The very best systems will even look at your RVU sequencing to ensure maximum reimbursement.
This procedure gives the staff time for you to correct the claim before it really is submitted, which makes it much less likely the claim will be denied and then must be resubmitted. Remember, the carriers generate income the longer they are able to hold onto your instalments. A great claim scrubber will help even playing field. All carriers use their very own version of the claim scrubber whenever they receive claims by you.
Using the mandates from Medicare along with all the other carriers following suit, you simply do not want to not go electronic. All facets of your practice could be enhanced using the HIPAA standards of electronic data exchange. As the initial investment in hardware, software and training might cost tens of thousands of dollars, the appropriate utilisation of the technology virtually guarantees a rapid return on the investment.