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Much like the major financial institutions closely pursuing the lead of the Federal Reserve, health insurance carriers adhere to the lead of Medicare. Medicare is becoming serious about filing medical claims electronically. Yes, avoiding hassles from Medicare is just one piece of the puzzle. What about the commercial carriers? Should you be not fully utilizing each of the electronic options at your disposal, you are losing money. In this post, I will 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 possibilities for going electronic.

Medicare recently began putting some pressure on providers to start out filing electronically. Physicians who carry on and submit a very high level of paper claims will receive a Medicare “request for documentation,” which has to be completed within 45 days to verify their eligibility to submit paper claims. Denials are not susceptible to appeal. In essence that if you are not filing claims electronically, it can cost you extra time, money and hassles.

While there has been much groaning and distress over new 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 initial 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 ways to optimize the claims process.

Practitioners frequently accept insurance cards which 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, a complete 25 % resulted from eligibility issues. More specifically, 22 percent resulted from coverage termination or coverage lapses. Eligibility denials not merely create more work as research and rebilling, but they also increase the potential risk of nonpayment. Poor eligibility verification boosts the probability of failing to precertify with the correct carrier, which might 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 eligibility verification in medical billing allows practitioners to automate this process, increasing the number of patients and operations which can be correctly verified. This standard allows you to query eligibility many times through the patient’s care, from initial scheduling to billing. This sort of real-time feedback can help reduce billing problems. Using this process even more, there is at least one vendor of practice management software that integrates automatic electronic eligibility in to the practice management workflow.

A standard problem for most providers is unknowingly providing services that are not “authorized” by the payer. Even when authorization is given, it could be lost by the payer and denied as unauthorized until proof is provided. Researching the problem and giving proof for the carrier costs you money. The circumstance is even more acute with HMOs. Without the proper referral authorization, you risk providing free services by performing work that is certainly away from 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 will need in case you will find questions on the timeliness of requests or actual approval of services. An additional benefit from this automated precertification is a decrease in time as well as labor typically spent getting authorization via telephone or fax. With electronic authorization, your staff could have more time to get more procedures authorized and can not have trouble getting to a payer representative. Additionally, your employees will more efficiently identify out-of-network patients in the beginning and have a chance 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 seek the help 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 obtain 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 letting you give attention to patient care. A paper insurance claim typically 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 increase in cash available for the requirements a growing practice. Reduced labor, office supplies and postage all bring about the important thing of the practice when submitting claims electronically.

Continuous rebilling of unpaid claims creates denials for duplicate claims with every rebill processed by 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 enjoy hours on the phone checking claim status. Along with confirming claim receipt, you can also get details on the payment processing status. The reduction in denials lets your staff focus on more productive revenue recovery activities. You can use claim status information to your benefit by optimizing the timing of your claim inquiries. For example, if you know that electronic remittance advice and payment are received within 21 days coming from a specific payer, it is possible to create a whole new claim inquiry process on day 22 for many claims in that batch that are still not posted.

HIPAA’s electronic remittance advice process provides extremely valuable information in your practice. It will 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 significant reason behind denials.

Another major benefit from 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 excessively inflated A/R. This distortion also can make it more difficult that you should identify denial patterns with the carriers. You may also require a proactive approach with the remittance advice data and start a denial database to zero in on problem codes and problem carriers.

Due to HIPAA, nearly all major commercial carriers now provide free access to these electronic processes via their websites. Having a simple Internet connection, you can register at these websites and have real-time use of patient insurance information that was previously available only on the phone. 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 some time and the educational curve are minimal.

Registering at no cost use of individual carrier websites could be a significant improvement over paper for the practice. The drawback for this approach is that your staff must continually log in and out of multiple websites. A more unified approach is to use a sensible practice management application which includes full support for electronic data exchange with all the carriers. Depending on the form of software you utilize, your alternatives and expenses can vary as to how 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 for you. Many software vendors dictate the clearinghouse you have to use to submit claims. The cost is normally determined over a per-claim basis and can usually be negotiated, with prices starting around twenty-four cents per claim. When using billing software along with a clearinghouse is an efficient way to streamline procedures and maximize collections, it is crucial ejbexv closely monitor the performance of your clearinghouse. Providers should instruct their staff to file claims at the very least 3 times each week and verify receipt of the claims by reviewing the various reports provided by the clearinghouses.

These systems automatically review electronic claims before they may be sent out. They look for missing fields, misused modifiers, mismatched CPT and ICD-9 codes and produce a report of errors and omissions. The best systems may also examine your RVU sequencing to ensure maximum reimbursement.

This procedure affords the staff time to correct the claim before it is submitted, making it far less likely that the claim will likely be denied and then have to be resubmitted. Remember, the carriers make money the more time they can hold on to your payments. A good claim scrubber will help even the playing field. All carriers use their particular version of any claim scrubber whenever they receive claims from you.

With all the mandates from Medicare and with all other carriers following suit, you just do not want not to 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 might cost thousands of dollars, the correct utilization of the technology virtually guarantees a fast return on your investment.