Just like the major finance institutions closely pursuing the lead of the Federal Reserve, medical insurance carriers follow the lead of Medicare. Medicare is getting seriously interested in filing medical claims electronically. Yes, avoiding hassles from Medicare is just one piece of the puzzle. What about the commercial carriers? If you are not fully utilizing all the electronic options at your disposal, you might be losing money. In this article, 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 boost your bottom line. We’ll also explore possibilities for going electronic.

Medicare recently began putting some pressure on providers to start filing electronically. Physicians who still submit a higher level of paper claims will receive a Medicare “request documentation,” which has to be completed within 45 days to confirm their eligibility to submit paper claims. Denials usually 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 rules and regulations heaved upon us by HIPAA (the medical Insurance Portability and Accountability Act of 1996), there is 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 offering five methods to optimize the claims process.

Practitioners frequently accept insurance cards which are invalid, expired, or perhaps 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. Specifically, 22 percent resulted from coverage termination or coverage lapses. Eligibility denials not just create more work as research and rebilling, they also increase the risk of nonpayment. Poor eligibility verification increases the chance 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 verify patient insurance eligibility allows practitioners to automate this method, increasing the number of patients and operations which can be correctly verified. This standard enables you to query eligibility multiple times throughout the patient’s care, from initial scheduling to billing. This kind of real-time feedback can help reduce billing problems. Using this process further, there exists at least one vendor of practice management software that integrates automatic electronic eligibility in to the practice management workflow.

A common problem for most providers is unknowingly providing services which are not “authorized” through the payer. Even if authorization is given, it could be lost from the payer and denied as unauthorized until proof is offered. Researching the matter and giving proof towards the carrier costs you cash. 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 most services. With this particular electronic record of authorization, you will have the documentation you will need in case you can find questions about the timeliness of requests or actual approval of services. An extra benefit from this automated precertification is a reduction in time and labor typically spent getting authorization via telephone or fax. With electronic authorization, your staff will have additional time to obtain more procedures authorized and will not have trouble arriving at a payer representative. Additionally, your employees will better identify out-of-network patients initially 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 may be beneficial to find the assistance of a medical management vendor for support with this particular labor-intensive process.

Submitting claims electronically is regarded as the fundamental process out from the five HIPPA tools. By processing your claims electronically you obtain 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 cost of claims processing and streamlines internal processes enabling you to give attention to patient care. A paper insurance claim normally takes about 45 days for reimbursement, where average payment time for electronic claims is 14 days. The reduction 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 bring about the important thing of your 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 a substitute for paying your staff 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 reduction in denials lets your staff focus on more productive revenue recovery activities. You can utilize claim status information to your advantage 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 from a specific payer, you can setup a brand new claim inquiry process on day 22 for those claims in this batch which can be still not posted.

HIPAA’s electronic remittance advice process can offer extremely valuable information for your practice. It does much more than simply keep 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 – a significant reason for denials.

Another major reap the benefits 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,” causing an overly inflated A/R. This distortion also causes it to be harder for you to identify denial patterns using the carriers. You may also have a proactive approach with the remittance advice data and commence a denial database to zero in on problem codes and problem carriers.

Because of HIPAA, almost all major commercial carriers now provide free use of these electronic processes via their websites. Having a simple Internet connection, you can register at websites like these and possess real-time use of patient insurance information that used to be available only by phone. Including the 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 and the training curve are minimal.

Registering at no cost usage of individual carrier websites could be a significant improvement over paper to your practice. The drawback to this particular approach is your staff must continually log inside and out of multiple websites. A far more unified approach is to apply a good 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 alternatives and costs may vary as to how you submit claims. Medicare offers the option to submit claims at no cost directly via dial-up connection.

Alternately, you could have the option to use a clearinghouse that receives your claims for Medicare along with other carriers and submits them to suit your needs. Many software vendors dictate the clearinghouse you must use to submit claims. The price is normally determined on the per-claim basis and may usually be negotiated, with prices starting around twenty-four cents per claim. While using the billing software and a clearinghouse is an excellent method to streamline procedures and maximize collections, it is crucial ejbexv closely monitor the performance of your own clearinghouse. Providers should instruct their staff to submit claims a minimum of 3 x a week and verify receipt of the claims by reviewing the various reports offered by the clearinghouses.

These systems automatically review electronic claims before these are sent out. 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 make certain maximum reimbursement.

This process gives the staff time to correct the claim before it is actually submitted, rendering it far less likely the claim will likely be denied then must be resubmitted. Remember, the carriers earn money the longer they can hold on to your instalments. A good claim scrubber can help even playing field. All carriers use their particular version of a claim scrubber when they receive claims from you.

With all the mandates from Medicare with all the other carriers following suit, you merely do not want to not go electronic. All aspects of the practice may be enhanced using the HIPAA standards of electronic data exchange. Whilst the initial investment in hardware, software and training could cost tens of thousands of dollars, the correct use of the technology virtually guarantees a fast return on your own investment.