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Medical Eligibility Verification – Why Examine More At This Characteristic..

Similar to the major financial institutions closely pursuing the lead of the Federal Reserve, health insurance carriers follow the lead of Medicare. Medicare is becoming seriously interested in filing medical claims electronically. Yes, avoiding hassles from Medicare is only one part of the puzzle. How about the commercial carriers? Should you be not fully utilizing each of the electronic options at your disposal, you are losing money. In this article, I will discuss five key electronic business processes that all major payers must support and just how you can use them to dramatically enhance your bottom line. We’ll also explore available options for going electronic.

Medicare recently began putting some pressure on providers to start filing electronically. Physicians who continue to submit a high amount 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 usually are not susceptible to appeal. The bottom line is that in case you are not filing claims electronically, it will cost you additional time, money and hassles.

While we have seen much groaning and distress over new rules and regulations heaved upon us by HIPAA (the medical Insurance Portability and Accountability Act of 1996), there exists a silver lining. With HIPAA, Congress mandated the very first electronic data standards for routine business processes between insurance companies and providers. These new standards usher in a new era for providers by providing five ways to optimize the claims process.

Practitioners frequently accept insurance cards that are invalid, expired, or even faked. The Health Insurance Association of America (HIAA) found in a 2003 study that 14 percent of claims were denied. Out of that percentage, an entire 25 % resulted from eligibility issues. Specifically, 22 percent resulted from coverage termination and/or coverage lapses. Eligibility denials not merely create more work in the form of research and rebilling, but they also increase the potential risk of nonpayment. Poor eligibility verification raises the probability of failing 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 cause you to miss the carrier’s timely filing requirements.

Use of the medi-cal eligibility verification system allows practitioners to automate this method, increasing the amount of patients and procedures that are correctly verified. This standard lets you query eligibility several 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 at least 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 when authorization is provided, it might be lost from the payer and denied as unauthorized until proof is offered. Researching the issue and giving proof for the carrier costs you cash. The circumstance is a lot more acute with HMOs. Without proper 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 most services. Using this electronic record of authorization, you will find the documentation you need in case there are questions on the timeliness of requests or actual approval of services. An extra benefit of this automated precertification is a decrease in time and labor typically spent getting authorization via telephone or fax. With electronic authorization, your staff could have additional time to get additional procedures authorized and can not have trouble getting to a payer representative. Additionally, your employees will more effectively identify out-of-network patients at first and 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 is a good idea 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 out from the five HIPPA tools. By processing your claims electronically you receive 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 cost of claims processing and streamlines internal processes enabling you to concentrate on patient care. A paper insurance claim normally takes about 45 days for reimbursement, where the average payment time for electronic claims is 14 days. The decline in insurance reimbursement time results in a significant boost in cash designed for the needs of a growing practice. Reduced labor, office supplies and postage all play a role in the conclusion of your own practice when submitting claims electronically.

Continuous rebilling of unpaid claims creates denials for duplicate claims with each rebill processed through the payer – causing more work for you and also the carrier. Using the HIPAA electronic claim status standard offers an alternative to paying your employees to invest hours on the phone checking claim status. In addition to confirming claim receipt, you can even get details on the payment processing status. The decline in denials lets your staff give attention to 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 from a specific payer, you are able to create a whole new claim inquiry process on day 22 for those claims because batch which are still not posted.

HIPAA’s electronic remittance advice process can offer extremely valuable information in your practice. It will much more than just save 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 – a major cause of denials.

Another major benefit from 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 so that you can identify denial patterns using the carriers. You can even have a proactive approach with all the remittance advice data and commence a denial database to zero in on problem codes and problem carriers.

Thanks to HIPAA, almost all major commercial carriers now provide free usage of these electronic processes via their websites. Using a simple Web connection, you can register at these web sites and also have real-time usage of patient insurance information that was once available only by telephone. Even smallest practice should think about registering to ensure eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and improve your provider profile. Registration some time and the educational curve are minimal.

Registering free of charge use of individual carrier websites could be a significant improvement over paper to your practice. The drawback to this particular approach is that your staff must continually log in and out of multiple websites. A more unified approach is by using a sensible practice management application that also includes full support for electronic data exchange with the carriers. Depending on the kind of software you make use of, your choices and costs can vary concerning how you will submit claims. Medicare supplies the choice to submit claims at no cost directly via dial-up connection.

Alternately, you could have an opportunity 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 need to use to submit claims. The fee is normally determined on a per-claim basis and can usually be negotiated, with prices starting around twenty-four cents per claim. When using billing software as well as a clearinghouse is an efficient approach 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 least 3 x 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 may be sent out. They look 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 ensure maximum reimbursement.

This procedure provides the staff time to correct the claim before it is actually submitted, rendering it much less likely the claim is going to be denied and after that must be resubmitted. Remember, the carriers generate income the more time they are able to hold to your payments. An excellent claim scrubber may help even playing field. All carriers use their very own version of any claim scrubber whenever they receive claims on your part.

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