Patient Eligibility Verification – What Exactly Some People Are Saying..

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Similar to the major finance institutions closely pursuing the lead of the Federal Reserve, medical health insurance carriers stick to the lead of Medicare. Medicare is becoming interested in filing medical claims electronically. Yes, avoiding hassles from Medicare is only one part of the puzzle. Have you thought about the commercial carriers? If you are not fully utilizing all the electronic options at your disposal, you might be losing money. In the following paragraphs, I will discuss five key electronic business processes that all major payers must support and just how they are utilized to dramatically boost your bottom line. We’ll also explore available options for going electronic.

Medicare recently began putting some pressure on providers to start out filing electronically. Physicians who still submit a very high volume of paper claims will receive a Medicare “request documentation,” which must be completed within 45 days to confirm their eligibility to submit paper claims. Denials usually are not subject to appeal. In essence that if you are not filing claims electronically, it can cost you additional time, money and hassles.

While there has been much groaning and distress over new regulations and rules heaved upon us by HIPAA (the Health 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 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 just create more work by means of research and rebilling, in addition they increase the potential risk of nonpayment. Poor eligibility verification raises the likelihood of neglecting to precertify with all the correct carrier, which can then result in a clinical denial. Furthermore, time wasted as a result of incorrect eligibility verification can make you miss the carrier’s timely filing requirements.

Use of the medi cal eligibility check allows practitioners to automate this procedure, increasing the quantity of patients and procedures which can be correctly verified. This standard allows 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 even more, there is a minumum of one 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” from the payer. Even if authorization is given, it could be lost through the payer and denied as unauthorized until proof is offered. Researching the problem and giving proof to the carrier costs you money. The situation is even more acute with HMOs. Without proper referral authorization, you risk providing free services by performing work which is outside the network.

The HIPAA referral request and authorization process allows providers to automate the requests and logging of authorization for a lot of services. With this electronic record of authorization, you have the documentation you need just in case you will find questions about the timeliness of requests or actual approval of services. Yet another advantage of this automated precertification is a reduction in some time and labor typically spent getting authorization via telephone or fax. With electronic authorization, your employees may have additional time to get more procedures authorized and will never have trouble reaching a payer representative. Additionally, your employees will more effectively identify out-of-network patients initially and also have a opportunity 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 find the help of a medical management vendor for support with this labor-intensive process.

Submitting claims electronically is regarded as the fundamental process 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 income, reduces the cost of claims processing and streamlines internal processes enabling you to focus on patient care. A paper insurance claim typically 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 rise in cash designed for the requirements of an increasing practice. Reduced labor, office supplies and postage all play a role in the important thing of the practice when submitting claims electronically.

Continuous rebilling of unpaid claims creates denials for duplicate claims with every rebill processed through the payer – causing more meet your needs as well as the carrier. Making use of the HIPAA electronic claim status standard offers an alternative to 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 decrease 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 the claim inquiries. For instance, if you know that electronic remittance advice and payment are received within 21 days coming from a specific payer, you can set up a whole new claim inquiry process on day 22 for all claims in that batch which are still not posted.

HIPAA’s electronic remittance advice process can provide extremely valuable information for your practice. It can much more than simply keep your staff effort and time. It increases the timeliness and accuracy of postings. Reducing the time between payment and posting greatly reduces the appearance of rebilling of open accounts – an important cause of 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 forget to post the “zero dollar payments,” resulting in an overly inflated A/R. This distortion also can make it more difficult so that you can identify denial patterns using the carriers. You may also take a proactive approach using the remittance advice data and begin a denial database to zero in on problem codes and problem carriers.

Because of HIPAA, virtually all major commercial carriers now provide free access to these electronic processes via their websites. Using a simple Internet access, you are able to register at websites like these and also have real-time use of patient insurance information that was once available only on the phone. Including the smallest practice should look into registering to verify eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and enhance your provider profile. Registration time as well as the training curve are minimal.

Registering at no cost usage of individual carrier websites can be a significant improvement over paper to your practice. The drawback for this approach is your staff must continually log out and in of multiple websites. A much more unified approach is to use a good practice management application which includes full support for electronic data exchange using the carriers. Depending on the kind of software you make use of, your alternatives and costs can vary greatly regarding how you submit claims. Medicare offers the choice to submit claims at no cost directly via dial-up connection.

Alternately, you may have an opportunity to use a clearinghouse that receives your claims for Medicare and other carriers and submits them to suit your needs. Many software vendors dictate the clearinghouse you need to use to submit claims. The fee is generally determined over 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 excellent approach to streamline procedures and maximize collections, it is crucial ejbexv closely monitor the performance of the clearinghouse. Providers should instruct their staff to submit claims at the very least 3 times per week and verify receipt of those claims by reviewing the various reports offered by the clearinghouses.

These systems automatically review electronic claims before they 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 check your RVU sequencing to make certain maximum reimbursement.

This procedure gives the staff time to correct the claim before it is actually submitted, rendering it less likely the claim will be denied then have to be resubmitted. Remember, the carriers earn money the more they are able to hold on to your instalments. A good claim scrubber can help even playing field. All carriers use their particular version of the claim scrubber whenever they receive claims on your part.

Using the mandates from Medicare with all other carriers following suit, you simply do not want to never go electronic. All facets of your practice may 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 appropriate utilization of the technology virtually guarantees a fast return on your investment.