Similar to the major financial institutions closely following the lead of the Federal Reserve, medical health insurance carriers stick 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? Should you be not fully utilizing each of the electronic options at your disposal, you are losing money. In the following paragraphs, I will discuss five key electronic business processes that all major payers must support and how you can use them to dramatically boost 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 still submit a very high level of paper claims will get a Medicare “request for documentation,” which must be completed within 45 days to ensure 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 cost you more time, money and hassles.
While we have seen much groaning and distress over new regulations heaved upon us by HIPAA (the medical Insurance Portability and Accountability Act of 1996), there exists a silver lining. With HIPAA, Congress mandated the very first electronic data standards for routine business processes between insurance carriers 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 the claims were denied. Out of 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 in the form of research and rebilling, but they also increase the chance of nonpayment. Poor eligibility verification increases the probability of failing to precertify with all the correct carrier, which might then result in a clinical denial. Furthermore, time wasted due to incorrect eligibility verification can make you miss the carrier’s timely filing requirements.
Use of the medicare eligibility verification for providers allows practitioners to automate this method, increasing the amount of patients and operations which are correctly verified. This standard lets you query eligibility multiple times through the patient’s care, from initial scheduling to billing. This type of real-time feedback can help 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 typical problem for many providers is unknowingly providing services that are not “authorized” from the payer. Even if authorization is offered, it could be lost through the payer and denied as unauthorized until proof is given. Researching the matter and giving proof to the carrier costs you money. The circumstance is a lot more acute with HMOs. Without the 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 a lot of services. With this particular electronic record of authorization, you will have the documentation you need just in case you can find questions about the timeliness of requests or actual approval of services. An additional benefit from this automated precertification is a decrease in some time and labor typically spent getting authorization via telephone or fax. With electronic authorization, your staff will have more time to get more procedures authorized and will not have trouble arriving at a payer representative. Additionally, your employees will more effectively identify out-of-network patients in the beginning and also 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 help of a medical management vendor for support with this labor-intensive process.
Submitting claims electronically is easily the most fundamental process out of the five HIPPA tools. By processing your claims electronically you receive 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 allowing you to concentrate on patient care. A paper insurance claim normally takes about 45 days for reimbursement, where the average payment time for electronic claims is 14 days. The decrease in insurance reimbursement time results in a significant rise in cash available for the needs of a developing practice. Reduced labor, office supplies and postage all contribute to the conclusion of your own practice when submitting claims electronically.
Continuous rebilling of unpaid claims creates denials for duplicate claims with each rebill processed by the payer – causing more meet your needs and also the carrier. Using the HIPAA electronic claim status standard offers an alternative choice to paying your staff to invest hours on the phone checking claim status. As well as confirming claim receipt, you can even get details on the payment processing status. The reduction in denials lets your employees focus on more productive revenue recovery activities. You may use claim status information to your advantage by optimizing the timing of your claim inquiries. For instance, if you know that electronic remittance advice and payment are received within 21 days coming from a specific payer, you are able to create a brand new claim inquiry process on day 22 for many claims in this batch which can be still not posted.
HIPAA’s electronic remittance advice process can offer extremely valuable information in your practice. It will much more than simply save your staff effort and time. It improves the timeliness and accuracy of postings. Lowering the time between payment and posting greatly reduces the appearance of rebilling of open accounts – an important reason for denials.
Another major take advantage of electronic remittance advice is that 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 makes it more difficult so that you can identify denial patterns with the carriers. You can also take a proactive approach using the remittance advice data and commence a denial database to zero in on problem codes and problem carriers.
Because of HIPAA, nearly all major commercial carriers now provide free access to these electronic processes via their websites. With a simple Internet access, you can register at websites like these and also have real-time usage of patient insurance information that was once available only by telephone. Even the smallest practice should consider registering to verify eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and enhance your provider profile. Registration time and the training curve are minimal.
Registering for free access to individual carrier websites could be a significant improvement over paper for the practice. The drawback to this approach that the staff must continually log out and in of multiple websites. A more unified approach is by using a good practice management application that includes full support for electronic data exchange using the carriers. Depending on the kind of software you use, your choices and expenses can vary as to the way you submit claims. Medicare supplies the option to submit claims free of charge directly via dial-up connection.
Alternately, you might have the choice to utilize a clearinghouse that receives your claims for Medicare as well as other carriers and submits them for you personally. Many software vendors dictate the clearinghouse you need to use to submit claims. The price is generally determined on a per-claim basis and will usually be negotiated, with prices starting around twenty-four cents per claim. While using the billing software as well as a clearinghouse is an excellent approach to streamline procedures and maximize collections, it is necessary ejbexv closely monitor the performance of your clearinghouse. Providers should instruct their staff to file claims at least three times each week and verify receipt of these claims by reviewing the many reports offered by the clearinghouses.
These systems automatically review electronic claims before these are sent. 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 check your RVU sequencing to ensure maximum reimbursement.
This procedure provides the staff time and energy to correct the claim before it is actually submitted, making it much less likely the claim will likely be denied then need to be resubmitted. Remember, the carriers earn money the more time they could hold onto your payments. A great claim scrubber will help even the playing field. All carriers use their particular version of a claim scrubber whenever they receive claims on your part.
With all the mandates from Medicare along with all the other carriers following suit, you simply do not want to never go electronic. All aspects of your own practice can be enhanced using the HIPAA standards of electronic data exchange. As the initial investment in hardware, software and training could cost thousands of dollars, the correct utilisation of the technology virtually guarantees a fast return on your own investment.