Similar to the major financial institutions closely following the lead of the Federal Reserve, medical insurance carriers follow the lead of Medicare. Medicare is getting serious about filing medical claims electronically. Yes, avoiding hassles from Medicare is only one piece of the puzzle. How about the commercial carriers? Should you be not fully utilizing all of the electronic options at your disposal, you might be 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 possibilities for going electronic.
Medicare recently began putting some pressure on providers to begin filing electronically. Physicians who still submit a high amount of paper claims will get a Medicare “request for documentation,” which must be completed within 45 days to verify their eligibility to submit paper claims. Denials are not subject to appeal. In essence that in case you are not filing claims electronically, it will set you back more time, money and hassles.
While we have seen much groaning and distress over new rules and regulations heaved upon us by HIPAA (the Health Insurance Portability and Accountability Act of 1996), you will find 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 by providing five approaches to optimize the claims process.
Practitioners frequently accept insurance cards which are invalid, expired, or even faked. The Medical Insurance Association of America (HIAA) found in a 2003 study that 14 percent of all claims were denied. Away from that percentage, a complete 25 percent 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 potential risk of nonpayment. Poor eligibility verification boosts the likelihood of neglecting to precertify with the correct carrier, which might then result in a clinical denial. Furthermore, time wasted due to incorrect eligibility verification can lead you to miss the carrier’s timely filing requirements.
Utilization of the eligibility verification system allows practitioners to automate this procedure, increasing the quantity of patients and procedures which can be 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. Taking this process further, there is certainly a minumum of 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 that are not “authorized” by the payer. Even if authorization is given, it may be lost through the payer and denied as unauthorized until proof is offered. Researching the matter and giving proof to the carrier costs you money. The circumstance is much more acute with HMOs. Without the proper referral authorization, you risk providing free services by performing work that is certainly outside the network.
The HIPAA referral request and authorization process allows providers to automate the requests and logging of authorization for many services. With this particular electronic record of authorization, you will have the documentation you will need in the event there are questions about the timeliness of requests or actual approval of services. An extra advantage of this automated precertification is a reduction in time and labor typically spent getting authorization via telephone or fax. With electronic authorization, your staff could have more time to obtain more procedures authorized and definately will not have trouble reaching a payer representative. Additionally, your staff will better identify out-of-network patients at first and have a opportunity to request an exception. While extremely useful, electronic referral requests and authorizations are certainly not yet fully implemented by all payers. It is a good idea to get the help of a medical management vendor for support with this particular labor-intensive process.
Submitting claims electronically is the most fundamental process out from the five HIPPA tools. By processing your claims electronically you receive 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 fee for claims processing and streamlines internal processes enabling you to 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 decline in insurance reimbursement time results in a significant increase in cash designed for the needs of a growing practice. Reduced labor, office supplies and postage all play a role in 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. Making use of the HIPAA electronic claim status standard offers an alternative choice to paying your employees to invest hours on the phone checking claim status. In addition to confirming claim receipt, you can 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 in your favor by optimizing the timing of your own claim inquiries. For instance, once you know that electronic remittance advice and payment are received within 21 days coming from a specific payer, it is possible to set up a brand new claim inquiry process on day 22 for many claims in that batch which can be still not posted.
HIPAA’s electronic remittance advice process can provide extremely valuable information for your practice. It does much not only save your valuable staff time and energy. It increases the timeliness and accuracy of postings. Reducing the time between payment and posting greatly reduces the occurrence of rebilling of open accounts – a major cause of 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,” resulting in 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 require a proactive approach with all the remittance advice data and commence a denial database to zero in on problem codes and problem carriers.
Due to HIPAA, almost all major commercial carriers now provide free use of these electronic processes via their websites. With a simple Internet access, you can register at these websites and have real-time access to patient insurance information that used to be available only by phone. Including the 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 and the educational curve are minimal.
Registering at no cost access to individual carrier websites can be a significant improvement over paper to your practice. The drawback to this particular approach is your staff must continually log out and in of multiple websites. A far more unified approach is to apply a good practice management application which includes full support for electronic data exchange with all the carriers. Depending on the form of software you use, your options and expenses can vary regarding the way you submit claims. Medicare supplies the solution to submit claims free of charge directly via dial-up connection.
Alternately, you could have an opportunity 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 fee 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 along with a clearinghouse is an excellent way to streamline procedures and maximize collections, it is crucial ejbexv closely monitor the performance of the clearinghouse. Providers should instruct their staff to file claims at the very least 3 times a week and verify receipt of the claims by reviewing the various reports provided by the clearinghouses.
These systems automatically review electronic claims before they are sent. 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 may also examine your RVU sequencing to ensure maximum reimbursement.
This process affords the staff time to correct the claim before it is submitted, rendering it much less likely that this claim is going to be denied and after that must be resubmitted. Remember, the carriers make money the more they can hold on to your instalments. An excellent claim scrubber may help including the playing field. All carriers use their own version of the claim scrubber once they receive claims by you.
With all the mandates from Medicare with all the other carriers following suit, you just do not want to never go electronic. All facets of the practice may be enhanced by the use of the HIPAA standards of electronic data exchange. While 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 your own investment.