Medical Insurance Eligibility – There May Be More Than What You Know Already On This Page..

Similar to the major financial institutions closely following the lead of the Federal Reserve, medical insurance carriers adhere to the lead of Medicare. Medicare is getting interested in filing medical claims electronically. Yes, avoiding hassles from Medicare is only one piece of the puzzle. What about the commercial carriers? Should you be not fully utilizing all the electronic options at your disposal, you are losing money. In this post, I am going to discuss five key electronic business processes that all major payers must support and exactly how you can use them to dramatically improve your bottom line. We’ll also explore available options for going electronic.

Medicare recently began putting some pressure on providers to begin filing electronically. Physicians who carry on and submit a high level of paper claims will get a Medicare “request documentation,” which should be completed within 45 days to ensure their eligibility to submit paper claims. Denials are not subject to appeal. In essence that if 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 rules and regulations heaved upon us by HIPAA (the Insurance Portability and Accountability Act of 1996), there exists a silver lining. With HIPAA, Congress mandated the initial electronic data standards for routine business processes between insurance carriers 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 which can be invalid, expired, or even faked. The Medical Insurance Association of America (HIAA) found in a 2003 study that 14 percent of claims were denied. Out of that percentage, a full 25 % resulted from eligibility issues. More specifically, 22 percent resulted from coverage termination and coverage lapses. Eligibility denials not only create more work in the form of research and rebilling, but they also increase the chance of nonpayment. Poor eligibility verification increases the likelihood of failing to precertify with all the correct carrier, which may 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.

Utilisation of the electronic eligibility verification allows practitioners to automate this process, increasing the quantity of patients and operations which are correctly verified. This standard enables you to query eligibility many times throughout the patient’s care, from initial scheduling to billing. This sort of real-time feedback can greatly reduce billing problems. Taking this process further, there exists one or more vendor of practice management software that integrates automatic electronic eligibility into the practice management workflow.

A typical problem for most providers is unknowingly providing services which are not “authorized” through the payer. Even though authorization is provided, it may be lost through the payer and denied as unauthorized until proof is provided. Researching the issue and giving proof for the carrier costs you money. The situation is even more acute with HMOs. Without the right 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. Using this electronic record of authorization, you will have the documentation you require in case there are questions on the timeliness of requests or actual approval of services. Yet another advantage of 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 hours 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 initially and have a possiblity 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 find the help of a medical management vendor for support with this labor-intensive process.

Submitting claims electronically is easily 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 cash flow, reduces the fee for claims processing and streamlines internal processes letting you concentrate on 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 decrease in insurance reimbursement time results in a significant boost in cash readily available for the needs of a developing practice. Reduced labor, office supplies and postage all contribute to 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 and the carrier. Using the HIPAA electronic claim status standard offers an alternative to paying your staff to spend hours on the phone checking claim status. As well as confirming claim receipt, you can also get details on the payment processing status. The decline in denials lets your employees concentrate on more productive revenue recovery activities. You may use claim status information to your benefit by optimizing the timing of your own claim inquiries. As an example, once you learn that electronic remittance advice and payment are received within 21 days coming from a specific payer, you are able to set up a whole new claim inquiry process on day 22 for all 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 will much more than simply keep your staff time and energy. It increases 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 behind denials.

Another major reap the benefits of electronic remittance advice is the fact that all adjustments are posted. Without it timely information, you data entry personnel may forget to post the “zero dollar payments,” causing an excessively inflated A/R. This distortion also can make it more challenging so that you can identify denial patterns with the carriers. You can also take 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, nearly all major commercial carriers now provide free usage of these electronic processes via their websites. Using a simple Web connection, you are able to register at these web sites and have real-time access to patient insurance information that was previously available only by telephone. 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 access to individual carrier websites can be quite a significant improvement over paper to your practice. The drawback for this approach that the staff must continually log inside 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 the carriers. Depending on the kind of software you use, your choices and expenses can vary greatly as to how you submit claims. Medicare offers the choice to submit claims free of charge directly via dial-up connection.

Alternately, you might have the choice to use a clearinghouse that receives your claims for Medicare as well as other carriers and submits them for you personally. Many software vendors dictate the clearinghouse you must use to submit claims. The cost is usually determined on a per-claim basis and can usually be negotiated, with prices starting around twenty-four cents per claim. When using billing software and 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 submit claims at the very least 3 x a week and verify receipt of those claims by reviewing the various 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 generate a report of errors and omissions. The best systems may also examine your RVU sequencing to make certain maximum reimbursement.

This method gives the staff time and energy to correct the claim before it really is submitted, rendering it far less likely the claim will be denied and after that must be resubmitted. Remember, the carriers earn money the more time they could hold to your payments. A great claim scrubber will help even the playing field. All carriers use their own version of the claim scrubber once they receive claims by you.

Using the mandates from Medicare with all other carriers following suit, you just cannot afford not to go electronic. All aspects of your practice can be enhanced by the use of the HIPAA standards of electronic data exchange. As the initial investment in hardware, software and training could cost thousands of dollars, the correct utilisation of the technology virtually guarantees a rapid return on your own investment.