Similar to the major finance institutions closely pursuing the lead of the Federal Reserve, medical insurance carriers stick to the lead of Medicare. Medicare is getting seriously interested in filing medical claims electronically. Yes, avoiding hassles from Medicare is only one piece of the puzzle. Have you thought about the commercial carriers? If you are not fully utilizing each of the electronic options at your disposal, you might be losing money. In this post, I will discuss five key electronic business processes that all major payers must support and how you can use them to dramatically enhance 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 carry on and submit a high amount of paper claims will get a Medicare “request documentation,” which must be completed within 45 days to ensure their eligibility to submit paper claims. Denials usually are not susceptible to appeal. The end result is that in case you are not filing claims electronically, it will set you back extra 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), there exists a silver lining. With HIPAA, Congress mandated the first electronic data standards for routine business processes between insurance companies and providers. These new standards usher in a new era for providers through providing five approaches to optimize the claims process.
Practitioners frequently accept insurance cards that are invalid, expired, as well as faked. The Medical Insurance Association of America (HIAA) found in a 2003 study that 14 percent of all the claims were denied. Away from that percentage, an entire 25 percent resulted from eligibility issues. More specifically, 22 percent resulted from coverage termination and coverage lapses. Eligibility denials not just create more work in the form of research and rebilling, they also increase the chance of nonpayment. Poor eligibility verification boosts the chance 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 cause you to miss the carrier’s timely filing requirements.
Use of the check medi-cal eligibility allows practitioners to automate this procedure, increasing the amount of patients and procedures that are correctly verified. This standard allows you to query eligibility several times during the patient’s care, from initial scheduling to billing. This kind of real-time feedback can help reduce billing problems. Using this process even further, 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 many providers is unknowingly providing services that are not “authorized” by the payer. Even when authorization is offered, it may be lost by the payer and denied as unauthorized until proof is offered. Researching the issue and giving proof for the carrier costs serious cash. The situation is much more acute with HMOs. Without the right 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 particular electronic record of authorization, you will have the documentation you need in the event you can find questions about the timeliness of requests or actual approval of services. Yet another benefit of this automated precertification is a reduction in time and labor typically spent getting authorization via telephone or fax. With electronic authorization, your staff may have more time to obtain more procedures authorized and can not have trouble arriving at a payer representative. Additionally, your staff will more effectively identify out-of-network patients at first and also have a possiblity 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 find the assistance of a medical management vendor for support with this particular labor-intensive process.
Submitting claims electronically is the most fundamental process from the five HIPPA tools. By processing your claims electronically you receive priority processing. Your electronically submitted claims go directly 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 allowing you to concentrate on patient care. A paper insurance claim normally takes about 45 days for reimbursement, in which the average payment time for electronic claims is 14 days. The decrease in insurance reimbursement time results in a significant boost in cash readily available for the requirements of an increasing practice. Reduced labor, office supplies and postage all bring about the important thing of your own practice when submitting claims electronically.
Continuous rebilling of unpaid claims creates denials for duplicate claims with each rebill processed from the payer – causing more meet your needs and also the carrier. Utilizing the HIPAA electronic claim status standard offers an alternative choice to paying your staff to invest hours on the phone checking claim status. Along with confirming claim receipt, you can even 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 your own claim inquiries. For instance, if you know that electronic remittance advice and payment are received within 21 days coming from a specific payer, it is possible to setup a brand new claim inquiry process on day 22 for all claims because batch which are still not posted.
HIPAA’s electronic remittance advice process provides extremely valuable information for your practice. It can much more than simply save your 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 – an important 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 fail to post the “zero dollar payments,” leading to an excessively inflated A/R. This distortion also makes it more difficult that you should identify denial patterns using the carriers. You can even have a proactive approach with all the remittance advice data and begin a denial database to zero in on problem codes and problem carriers.
Thanks to HIPAA, nearly all major commercial carriers now provide free usage of these electronic processes via their websites. Having a simple Internet access, you can register at these websites and also have real-time access to patient insurance information that was previously available only on the phone. Even smallest practice should look into registering to confirm eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and improve your provider profile. Registration some time and the training curve are minimal.
Registering for free use of individual carrier websites can be a significant improvement over paper for your practice. The drawback to this approach that the staff must continually log in and out of multiple websites. A more unified approach is to apply a sensible practice management application that includes full support for electronic data exchange with the carriers. Depending on the kind of software you make use of, your options and expenses can vary greatly as to the way you submit claims. Medicare supplies the option to submit claims at no cost directly via dial-up connection.
Alternately, you may have the option to employ a clearinghouse that receives your claims for Medicare as well as other carriers and submits them to suit your needs. Many software vendors dictate the clearinghouse you must use to submit claims. The cost is generally determined over a per-claim basis and can 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 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 each week and verify receipt of those claims by reviewing the many 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 produce a report of errors and omissions. The best systems will even examine your RVU sequencing to ensure maximum reimbursement.
This process affords the staff time and energy to correct the claim before it really is submitted, rendering it far less likely that this claim will be denied then must be resubmitted. Remember, the carriers make money the more time they can hold on to your payments. An excellent claim scrubber may help even the playing field. All carriers use their own version of a claim scrubber when they receive claims from you.
Using the mandates from Medicare with other carriers following suit, you just cannot afford to never go electronic. Every aspect of your practice can be enhanced using the HIPAA standards of electronic data exchange. While the initial investment in hardware, software and training could cost tens of thousands of dollars, the proper use of the technology virtually guarantees a fast return on your own investment.