Similar to the major finance institutions closely following the lead of the Federal Reserve, medical insurance carriers adhere to the lead of Medicare. Medicare is getting serious about filing medical claims electronically. Yes, avoiding hassles from Medicare is just one part of the puzzle. Have you thought about the commercial carriers? Should you be not fully utilizing all of 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 just how you can use them to dramatically improve your bottom line. We’ll also explore available options for going electronic.
Medicare recently began putting some pressure on providers to begin filing electronically. Physicians who continue to submit a higher amount 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 certainly not subjected to appeal. In essence that should you be not filing claims electronically, it will cost you additional time, money and hassles.
While there has been much groaning and distress over new regulations and rules heaved upon us by HIPAA (the medical Insurance Portability and Accountability Act of 1996), there is 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 through providing five methods to optimize the claims process.
Practitioners frequently accept insurance cards that are invalid, expired, or perhaps faked. The 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 or coverage lapses. Eligibility denials not only create more work in the form of research and rebilling, but they also increase the potential risk of nonpayment. Poor eligibility verification boosts the likelihood of failing to precertify using the correct carrier, which may then result in a clinical denial. Furthermore, time wasted as a result of incorrect eligibility verification can cause you to miss the carrier’s timely filing requirements.
Utilization of the verify insurance eligibility allows practitioners to automate this method, increasing the quantity of patients and procedures which are correctly verified. This standard allows you to query eligibility multiple times during the patient’s care, from initial scheduling to billing. This type of real-time feedback can greatly reduce billing problems. Using this process even more, there is a minumum of one vendor of practice management software that integrates automatic electronic eligibility into the practice management workflow.
A standard problem for a lot of providers is unknowingly providing services which are not “authorized” through the payer. Even when authorization is provided, it may be lost from the payer and denied as unauthorized until proof is given. Researching the matter and giving proof for the carrier costs you cash. The situation is a lot 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 many services. With this electronic record of authorization, you will have the documentation you require just in case there are questions on the timeliness of requests or actual approval of services. Yet another benefit of this automated precertification is a reduction in some time and labor typically spent getting authorization via telephone or fax. With electronic authorization, your staff could have additional time to get more procedures authorized and can never have trouble getting to a payer representative. Additionally, your employees will more effectively identify out-of-network patients in the beginning and also a opportunity to request an exception. While extremely useful, electronic referral requests and authorizations are certainly not yet fully implemented by all payers. It may be beneficial to find the assistance of a medical management vendor for support using this labor-intensive process.
Submitting claims electronically is regarded as the fundamental process from 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 cashflow, reduces the fee for claims processing and streamlines internal processes enabling you to give attention to patient care. A paper insurance claim often takes about 45 days for reimbursement, where the average payment time for electronic claims is 14 days. The decline in insurance reimbursement time results in a significant increase in cash designed for the needs of an increasing practice. Reduced labor, office supplies and postage all play a role in the important thing of your own practice when submitting claims electronically.
Continuous rebilling of unpaid claims creates denials for duplicate claims with every rebill processed through the payer – causing more be right for you as well as the carrier. Making use of the HIPAA electronic claim status standard offers a substitute for paying your staff to invest hours on the phone checking claim status. As well as 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. For example, once you learn that electronic remittance advice and payment are received within 21 days from a specific payer, you are able to create a new claim inquiry process on day 22 for those claims because batch that are still not posted.
HIPAA’s electronic remittance advice process can offer extremely valuable information to your practice. It can much not only save your valuable staff effort and time. It improves the timeliness and accuracy of postings. Decreasing the time between payment and posting greatly reduces the occurrence of rebilling of open accounts – a major reason behind denials.
Another major benefit from electronic remittance advice is the fact 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 for you to identify denial patterns using the carriers. You may also take a proactive approach using the remittance advice data and commence a denial database to zero in on problem codes and problem carriers.
Due to HIPAA, virtually all major commercial carriers now provide free access to these electronic processes via their websites. Having a simple Internet connection, you are able to register at websites like these and have real-time access to patient insurance information that was previously available only by phone. Even smallest practice should look into registering to ensure eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and enhance your provider profile. Registration time as well as the training curve are minimal.
Registering for free use of individual carrier websites can be quite a significant improvement over paper for your practice. The drawback to this approach that the staff must continually log inside and out of multiple websites. A far more unified approach is to use a sensible practice management application that also 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 greatly concerning how you will submit claims. Medicare provides the solution to submit claims free of charge directly via dial-up connection.
Alternately, you may have an opportunity to use a clearinghouse that receives your claims for Medicare along with other carriers and submits them for you personally. Many software vendors dictate the clearinghouse you have to use to submit claims. The price is generally determined on the per-claim basis and will usually be negotiated, with prices starting around twenty-four cents per claim. While using billing software and a clearinghouse is an effective way to streamline procedures and maximize collections, it is important ejbexv closely monitor the performance of the clearinghouse. Providers should instruct their staff to submit claims a minimum of three times each week and verify receipt of those claims by reviewing the different reports provided by the clearinghouses.
These systems automatically review electronic claims before they may be sent. 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 will also check your RVU sequencing to make sure maximum reimbursement.
This procedure gives the staff time and energy to correct the claim before it is submitted, which makes it much less likely that this claim will be denied and then must be resubmitted. Remember, the carriers make money the more time they are able to hold onto your instalments. A good claim scrubber may help even the playing field. All carriers use their own version of the claim scrubber when they receive claims by you.
With all the mandates from Medicare with all the other carriers following suit, you merely cannot afford to not go electronic. All facets of the practice may be enhanced using the HIPAA standards of electronic data exchange. As the initial investment in hardware, software and training could cost hundreds and hundreds of dollars, the proper use of the technology virtually guarantees a fast return on your own investment.