Mass Health Insurance Eligibility – Can It Be Cheaper Than This..

Just like the major financial institutions closely pursuing the lead of the Federal Reserve, medical health insurance carriers stick 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. How about the commercial carriers? If you are not fully utilizing all the electronic options at your disposal, you are losing money. In the following paragraphs, I will 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 continue to submit a high level of paper claims will get a Medicare “request for documentation,” which has to be completed within 45 days to ensure their eligibility to submit paper claims. Denials are not susceptible to appeal. In essence that if you are not filing claims electronically, it will cost you more time, money and hassles.

While we have seen much groaning and distress over new 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 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 Insurance Association of America (HIAA) found in a 2003 study that 14 percent of all claims were denied. Away from that percentage, a full 25 percent resulted from eligibility issues. Specifically, 22 percent resulted from coverage termination and coverage lapses. Eligibility denials not just create more work as research and rebilling, 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.

Utilisation of the medical eligibility allows practitioners to automate this method, increasing the number of patients and procedures which can be correctly verified. This standard enables you to query eligibility multiple times through the patient’s care, from initial scheduling to billing. This type of real-time feedback can greatly reduce billing problems. Using this process further, there is certainly a minumum of one vendor of practice management software that integrates automatic electronic eligibility to the practice management workflow.

A typical problem for a lot of providers is unknowingly providing services that are not “authorized” from the payer. Even if authorization is provided, it might be lost from the payer and denied as unauthorized until proof is offered. Researching the issue and giving proof towards the carrier costs serious cash. The circumstance is a lot more acute with HMOs. Without the right referral authorization, you risk providing free services by performing work that is outside the network.

The HIPAA referral request and authorization process allows providers to automate the requests and logging of authorization for many services. Using this electronic record of authorization, you have the documentation you need in case you will find questions on the timeliness of requests or actual approval of services. An extra benefit from this automated precertification is a decrease in some time and labor typically spent getting authorization via telephone or fax. With electronic authorization, your employees will have additional time to get more procedures authorized and definately will not have trouble arriving at a payer representative. Additionally, your staff will more efficiently 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 may be beneficial to get the assistance of a medical management vendor for support using this labor-intensive process.

Submitting claims electronically is the most fundamental process out of 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 fee for claims processing and streamlines internal processes enabling 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 reduction in insurance reimbursement time results in a significant increase in cash available for the requirements a developing practice. Reduced labor, office supplies and postage all contribute to the bottom line of your 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 and the carrier. Using the HIPAA electronic claim status standard offers an alternative choice to paying your employees to spend hours on the phone checking claim status. As well as confirming claim receipt, you may also get details on the payment processing status. The decline in denials lets your employees 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 example, 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 all claims in this batch which are still not posted.

HIPAA’s electronic remittance advice process can provide extremely valuable information to your practice. It will much more than simply save your staff time and energy. It increases the timeliness and accuracy of postings. Decreasing the time between payment and posting greatly reduces the occurrence of rebilling of open accounts – a significant cause of denials.

Another major benefit from electronic remittance advice is that all adjustments are posted. Without this timely information, you data entry personnel may forget to post the “zero dollar payments,” leading to an overly inflated A/R. This distortion also can make it harder for you to identify denial patterns with all the carriers. You can even have a proactive approach using the remittance advice data and begin a denial database to zero in on problem codes and problem carriers.

Thanks to HIPAA, virtually all major commercial carriers now provide free usage of these electronic processes via their websites. With a simple Internet connection, you are able to register at these web sites and have real-time access to patient insurance information that used to be available only by telephone. Including the smallest practice should think about 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 training curve are minimal.

Registering for free access to individual carrier websites can be a significant improvement over paper for your practice. The drawback for this approach is that your staff must continually log out and in of multiple websites. A far more unified approach is by using a sensible practice management application that includes full support for electronic data exchange with all the carriers. Depending on the type of software you make use of, your alternatives and expenses can vary greatly as to the way you submit claims. Medicare provides the choice to submit claims free of charge directly via dial-up connection.

Alternately, you might have an opportunity to use a clearinghouse that receives your claims for Medicare and other carriers and submits them for you. Many software vendors dictate the clearinghouse you need to use to submit claims. The price is usually determined on a 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 efficient way to streamline procedures and maximize collections, it is necessary ejbexv closely monitor the performance of your own clearinghouse. Providers should instruct their staff to submit claims at the very least 3 times a week and verify receipt of the claims by reviewing the different reports supplied by the clearinghouses.

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

This method affords the staff time and energy to correct the claim before it is submitted, making it much less likely the claim will be denied then need to be resubmitted. Remember, the carriers earn money the more they can hold onto your instalments. An excellent claim scrubber can help even playing field. All carriers use their very own version of any claim scrubber when they receive claims on your part.

Using the mandates from Medicare along with all other carriers following suit, you merely cannot afford to not go electronic. All aspects of your 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 proper use of the technology virtually guarantees a fast return on your own investment.