Medicare Eligibility Verification For Providers – With Exactly What Rationale Do You Need To Make A Decision..

Just like the major financial institutions closely pursuing the lead of the Federal Reserve, medical insurance carriers adhere to the lead of Medicare. Medicare is becoming interested in filing medical claims electronically. Yes, avoiding hassles from Medicare is just one part of the puzzle. Have you thought about the commercial carriers? Should you be not fully utilizing each of the electronic options at your disposal, you might be losing money. In this article, I will discuss five key electronic business processes that all major payers must support and 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 still submit a very high volume of paper claims will get a Medicare “ask for documentation,” which should be completed within 45 days to ensure their eligibility to submit paper claims. Denials are not subject to appeal. The end result is that if you are not filing claims electronically, it will cost you additional time, money and hassles.

While there has been much groaning and distress over new regulations heaved upon us by HIPAA (the Health Insurance Portability and Accountability Act of 1996), you will find 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 offering five methods to optimize the claims process.

Practitioners frequently accept insurance cards which are invalid, expired, or even faked. The Health Insurance Association of America (HIAA) found in a 2003 study that 14 percent of all the claims were denied. From that percentage, a complete 25 % resulted from eligibility issues. Specifically, 22 percent resulted from coverage termination and coverage lapses. Eligibility denials not only 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 neglecting to precertify using the correct carrier, which might then result in a clinical denial. Furthermore, time wasted as a result of incorrect eligibility verification can lead you to miss the carrier’s timely filing requirements.

Utilisation of the automated patient payment plans allows practitioners to automate this process, increasing the amount of patients and operations which can be correctly verified. This standard enables you to query eligibility many times throughout the patient’s care, from initial scheduling to billing. This kind of real-time feedback can greatly reduce billing problems. Using this process further, there is at least one vendor of practice management software that integrates automatic electronic eligibility in 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 offered, it might be lost by the payer and denied as unauthorized until proof is provided. 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 certainly outside of the network.

The HIPAA referral request and authorization process allows providers to automate the requests and logging of authorization for most services. With this electronic record of authorization, you have the documentation you require in the event you can find questions about the timeliness of requests or actual approval of services. Yet another benefit from this automated precertification is a reduction in some time and labor typically spent getting authorization via telephone or fax. With electronic authorization, your staff will have more hours to get additional procedures authorized and definately will never have trouble getting to a payer representative. Additionally, your staff will better identify out-of-network patients at first 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 great idea to seek the help of a medical management vendor for support using this labor-intensive process.

Submitting claims electronically is regarded as the fundamental process out from the five HIPPA tools. By processing your claims electronically you obtain priority processing. Your electronically submitted claims go right 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 expense of claims processing and streamlines internal processes allowing you to give attention to 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 increase in cash readily available for the needs of a growing practice. Reduced labor, office supplies and postage all play a role in the bottom line of your practice when submitting claims electronically.

Continuous rebilling of unpaid claims creates denials for duplicate claims with each rebill processed by the payer – causing more meet your needs as well as 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 also 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 the claim inquiries. For instance, if you know that electronic remittance advice and payment are received within 21 days coming from a specific payer, it is possible to create a whole new claim inquiry process on day 22 for all claims in this batch that are still not posted.

HIPAA’s electronic remittance advice process provides extremely valuable information for your practice. It will much more than just keep your staff effort and time. It improves the timeliness and accuracy of postings. Decreasing the time between payment and posting greatly reduces the occurrence of rebilling of open accounts – a major reason behind denials.

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

Due to HIPAA, virtually all major commercial carriers now provide free access to these electronic processes via their websites. With a simple Internet access, you can register at websites like these and also have real-time usage of patient insurance information that used to be available only by phone. Even smallest practice should look into registering to ensure eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and improve your provider profile. Registration time as well as the educational curve are minimal.

Registering free of charge use of individual carrier websites could be a significant improvement over paper for your practice. The drawback to this particular approach that the staff must continually log out and in 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 make use of, your alternatives and costs can vary greatly as to how you submit claims. Medicare provides the solution to submit claims at no cost directly via dial-up connection.

Alternately, you may have the option to utilize a clearinghouse that receives your claims for Medicare as well as 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 on a per-claim basis and may usually be negotiated, with prices starting around twenty-four cents per claim. While using the billing software along with a clearinghouse is an excellent method 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 a minimum of 3 x per week and verify receipt of these claims by reviewing the various reports provided 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 generate a report of errors and omissions. The very best systems will also look at your RVU sequencing to make certain maximum reimbursement.

This procedure provides the staff time for you to correct the claim before it is actually submitted, making it less likely the claim is going to be denied and then must be resubmitted. Remember, the carriers make money the more time they could hold to your instalments. An excellent claim scrubber can help even playing field. All carriers use their particular version of the claim scrubber whenever they receive claims from you.

Using the mandates from Medicare along with all the other carriers following suit, you just do not want to never go electronic. All facets of your practice could be enhanced by the use of the HIPAA standards of electronic data exchange. As the initial investment in hardware, software and training might cost tens of thousands of dollars, the correct utilization of the technology virtually guarantees a fast return on the investment.