Much like the major finance institutions closely pursuing 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 just one piece of the puzzle. What about the commercial carriers? If you are not fully utilizing all the electronic options at your disposal, you are losing money. In this post, I am going to discuss five key electronic business processes that all major payers must support and how they are utilized 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 out filing electronically. Physicians who still submit a higher volume of paper claims will get a Medicare “request documentation,” which should be completed within 45 days to verify their eligibility to submit paper claims. Denials are not susceptible to appeal. The end result is that in case you are not filing claims electronically, it will set you back additional time, money and hassles.
While there has been much groaning and distress over new regulations and rules heaved upon us by HIPAA (the 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 ways to optimize the claims process.
Practitioners frequently accept insurance cards which can be 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 % resulted from eligibility issues. Specifically, 22 percent resulted from coverage termination and/or coverage lapses. Eligibility denials not merely create more work as research and rebilling, they also increase the chance of nonpayment. Poor eligibility verification raises the probability of neglecting to precertify with all 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.
Use of the electronic insurance verification allows practitioners to automate this process, increasing the number of patients and operations which are correctly verified. This standard lets you query eligibility many times throughout the patient’s care, from initial scheduling to billing. This kind of real-time feedback can help reduce billing problems. Using this process further, there is one or more vendor of practice management software that integrates automatic electronic eligibility into the practice management workflow.
A standard problem for most providers is unknowingly providing services that are not “authorized” from the payer. Even when authorization is provided, it may be lost through the payer and denied as unauthorized until proof is provided. Researching the matter and giving proof to the carrier costs you money. The circumstance is even 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 a lot of services. Using this electronic record of authorization, you will have the documentation you need in case you will find questions regarding the timeliness of requests or actual approval of services. An extra 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 will have more hours to get more procedures authorized and definately will have never trouble arriving at a payer representative. Additionally, your staff will better identify out-of-network patients initially and also a opportunity to request an exception. While extremely useful, electronic referral requests and authorizations usually are not yet fully implemented by all payers. It is a good idea to find the assistance of a medical management vendor for support with this labor-intensive process.
Submitting claims electronically is the most fundamental process out 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 cash flow, reduces the cost of claims processing and streamlines internal processes letting you concentrate on patient care. A paper insurance claim often 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 boost in cash designed for the requirements of a growing practice. Reduced labor, office supplies and postage all bring about the conclusion 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 meet your needs and also the carrier. Using the HIPAA electronic claim status standard offers an alternative to paying your employees to enjoy hours on the phone checking claim status. Along with 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 utilize claim status information to your benefit by optimizing the timing of your own claim inquiries. As an example, once you learn that electronic remittance advice and payment are received within 21 days from a specific payer, you are able to setup a new claim inquiry process on day 22 for those claims in this batch that are still not posted.
HIPAA’s electronic remittance advice process can offer extremely valuable information to your practice. It does much more than just keep your staff time and effort. It improves the timeliness and accuracy of postings. Reducing the time between payment and posting greatly reduces the appearance of rebilling of open accounts – a significant cause of 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,” resulting in an excessively inflated A/R. This distortion also makes it more challenging so that you can identify denial patterns with all the carriers. You can also take a proactive approach with all the remittance advice data and begin a denial database to zero in on problem codes and problem carriers.
Due to HIPAA, nearly all major commercial carriers now provide free usage of these electronic processes via their websites. Having a simple Web connection, it is possible to register at these websites and possess real-time access to patient insurance information that used to be available only by telephone. Even smallest practice should consider registering to confirm eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and update your provider profile. Registration time as well as the training curve are minimal.
Registering at no cost access to individual carrier websites could be a significant improvement over paper for your practice. The drawback to this approach is that your staff must continually log in and out of multiple websites. A much more unified approach is to apply a good practice management application that also includes full support for electronic data exchange with all the carriers. Depending on the form of software you utilize, your options and expenses can vary as to the way you submit claims. Medicare provides the option 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 along with other carriers and submits them to suit your needs. Many software vendors dictate the clearinghouse you must use to submit claims. The fee is generally determined on the per-claim basis and may usually be negotiated, with prices starting around twenty-four cents per claim. When using billing software and a clearinghouse is an excellent approach to streamline procedures and maximize collections, it is important ejbexv closely monitor the performance of your own clearinghouse. Providers should instruct their staff to submit claims at the very least 3 x each week and verify receipt of the claims by reviewing the many reports provided by the clearinghouses.
These systems automatically review electronic claims before they may be sent. They look for missing fields, misused modifiers, mismatched CPT and ICD-9 codes and produce a report of errors and omissions. The best systems will even check your RVU sequencing to make sure maximum reimbursement.
This process provides the staff time to correct the claim before it is actually submitted, making it far less likely the claim will likely be denied then must be resubmitted. Remember, the carriers make money the more they could hold on to your payments. A great claim scrubber may help even the playing field. All carriers use their own version of the claim scrubber when they receive claims from you.
Using the mandates from Medicare along with all the other carriers following suit, you simply cannot afford to never go electronic. All facets of the practice can be enhanced through the HIPAA standards of electronic data exchange. Whilst the initial investment in hardware, software and training could cost thousands of dollars, the proper use of the technology virtually guarantees a rapid return on the investment.