Medicare Eligibility Verification – Upon What Justification Do You Need To Make A Choice..

Similar to the major finance institutions closely following the lead of the Federal Reserve, health insurance carriers stick to the lead of Medicare. Medicare is becoming serious about filing medical claims electronically. Yes, avoiding hassles from Medicare is just one part of the puzzle. Have you thought about the commercial carriers? If you are not fully utilizing each of the electronic options at your disposal, you might be losing money. In the following paragraphs, 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 enhance your bottom line. We’ll also explore options available for going electronic.

Medicare recently began putting some pressure on providers to start out filing electronically. Physicians who carry on and submit a very high volume of paper claims will get a Medicare “ask for documentation,” which must be completed within 45 days to verify their eligibility to submit paper claims. Denials are not subject to appeal. In essence that in case you are not filing claims electronically, it will set you back 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 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 that are invalid, expired, or perhaps faked. The Medical Insurance Association of America (HIAA) found in a 2003 study that 14 percent of all claims were denied. From that percentage, a complete 25 percent resulted from eligibility issues. More specifically, 22 percent resulted from coverage termination and coverage lapses. Eligibility denials not just create more work in the form of research and rebilling, in addition they 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.

Utilization of the medical eligibility allows practitioners to automate this procedure, increasing the number of patients and procedures which are correctly verified. This standard enables you to query eligibility many times throughout the patient’s care, from initial scheduling to billing. This type of real-time feedback can greatly reduce billing problems. Taking this process further, there is at least 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 could be lost through the payer and denied as unauthorized until proof is given. Researching the problem and giving proof to the carrier costs you cash. The situation is much more acute with HMOs. Without the right 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 most services. Using this electronic record of authorization, you will find the documentation you need in the event there are questions regarding the timeliness of requests or actual approval of services. An extra 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 will have additional time to get more procedures authorized and definately will have never trouble reaching a payer representative. Additionally, your staff will more efficiently identify out-of-network patients initially and have a opportunity to request an exception. While extremely useful, electronic referral requests and authorizations are not yet fully implemented by all payers. It is a good idea to seek the assistance of a medical management vendor for support using this labor-intensive process.

Submitting claims electronically is easily the most fundamental process from the five HIPPA tools. By processing your claims electronically you get 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 expense 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 boost in cash available for the requirements of an increasing 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 from the payer – causing more meet your needs and also the carrier. Making use of the HIPAA electronic claim status standard offers a substitute for paying your staff to invest 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 staff give attention to more productive revenue recovery activities. You may use claim status information in your favor by optimizing the timing of the claim inquiries. As an example, once you know that electronic remittance advice and payment are received within 21 days from the specific payer, you can set up a 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 provide extremely valuable information in your practice. It will much more than simply save your valuable staff time and energy. It increases the timeliness and accuracy of postings. Reducing the time between payment and posting greatly reduces the occurrence of rebilling of open accounts – a major cause of denials.

Another major benefit from electronic remittance advice is that all adjustments are posted. Without it timely information, you data entry personnel may fail to post the “zero dollar payments,” leading to an excessively inflated A/R. This distortion also makes it more difficult for you to identify denial patterns with all the carriers. You may also require a proactive approach using the remittance advice data and start a denial database to zero in on problem codes and problem carriers.

Thanks to HIPAA, almost all major commercial carriers now provide free access to these electronic processes via their websites. Having a simple Internet connection, it is possible to register at these web sites and have real-time use of patient insurance information that used to be available only on the phone. Even smallest practice should consider registering to verify eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and improve your provider profile. Registration time and the learning curve are minimal.

Registering at no cost use of individual carrier websites can be a significant improvement over paper to your practice. The drawback for this approach that the staff must continually log out and in of multiple websites. A much more unified approach is to apply a sensible practice management application that includes full support for electronic data exchange with all the carriers. Depending on the type of software you utilize, your choices and costs can vary regarding 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 and other carriers and submits them for you. Many software vendors dictate the clearinghouse you must use to submit claims. The fee is generally determined on the per-claim basis and may usually be negotiated, with prices starting around twenty-four cents per claim. While using billing software along with a clearinghouse is an excellent approach to streamline procedures and maximize collections, it is necessary ejbexv closely monitor the performance of the clearinghouse. Providers should instruct their staff to submit claims at least three times per week and verify receipt of those claims by reviewing the different reports supplied 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 most effective systems will also examine your RVU sequencing to ensure maximum reimbursement.

This method affords the staff time to correct the claim before it is actually submitted, making it much less likely that this claim will likely be denied and then need to be resubmitted. Remember, the carriers generate income the more they are able to hold to your payments. A good claim scrubber will help even the playing field. All carriers use their own version of the claim scrubber when they receive claims on your part.

With all the mandates from Medicare along with all other carriers following suit, you just cannot afford to never go electronic. Every aspect of your own practice may be enhanced using the HIPAA standards of electronic data exchange. Whilst the initial investment in hardware, software and training could cost thousands of dollars, the appropriate utilisation of the technology virtually guarantees a rapid return on the investment.