Medi-Cal Eligibility Verification System – So Why Research Deeper Directly Into This Point..

Similar to the major financial institutions closely following 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 piece of the puzzle. Have you thought about the commercial carriers? Should you be not fully utilizing all of the electronic options at your disposal, you are 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 enhance 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 continue to submit a high level of paper claims will receive a Medicare “ask for documentation,” which has to be completed within 45 days to verify their eligibility to submit paper claims. Denials are certainly not susceptible to appeal. The end result is that if 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 and rules 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 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 which are invalid, expired, as well as faked. The Health Insurance Association of America (HIAA) found in a 2003 study that 14 percent of claims were denied. From that percentage, an entire 25 percent resulted from eligibility issues. Specifically, 22 percent resulted from coverage termination or coverage lapses. Eligibility denials not only create more work as research and rebilling, in addition they increase the chance of nonpayment. Poor eligibility verification increases the chance of neglecting to precertify with all the correct carrier, which can then result in a clinical denial. Furthermore, time wasted because 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 method, increasing the number of patients and operations which are correctly verified. This standard lets you query eligibility several times through the patient’s care, from initial scheduling to billing. This sort of real-time feedback can greatly reduce billing problems. Using this process even further, there exists at least one vendor of practice management software that integrates automatic electronic eligibility to the practice management workflow.

A standard problem for most providers is unknowingly providing services which are not “authorized” through the payer. Even when authorization is given, it could be lost from the payer and denied as unauthorized until proof is provided. Researching the matter and giving proof towards the carrier costs you cash. The circumstance is even more acute with HMOs. Without the right 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 many services. Using this electronic record of authorization, you will have the documentation you will need in case you can find questions regarding the timeliness of requests or actual approval of services. An additional 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 may have more time to obtain more procedures authorized and will have never trouble getting to a payer representative. Additionally, your staff will better identify out-of-network patients in the beginning and have a possiblity 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 with this particular labor-intensive process.

Submitting claims electronically is easily the most fundamental process out of the five HIPPA tools. By processing your claims electronically you receive 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 cashflow, reduces the expense of claims processing and streamlines internal processes enabling you to give attention to patient care. A paper insurance claim often 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 readily available for the needs of an increasing practice. Reduced labor, office supplies and postage all bring about the bottom line of your own practice when submitting claims electronically.

Continuous rebilling of unpaid claims creates denials for duplicate claims with each rebill processed by the payer – causing more work for you as well as the carrier. Making use of the HIPAA electronic claim status standard offers an alternative to paying your employees to enjoy 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 employees give attention to more productive revenue recovery activities. You may use claim status information to your advantage by optimizing the timing of your claim inquiries. For instance, once you know that electronic remittance advice and payment are received within 21 days from a specific payer, you can setup a whole new claim inquiry process on day 22 for all claims in that batch which can be still not posted.

HIPAA’s electronic remittance advice process can offer extremely valuable information to your practice. It does much more than simply keep your staff time and energy. It improves the timeliness and accuracy of postings. Lowering the time between payment and posting greatly reduces the occurrence of rebilling of open accounts – a major reason for denials.

Another major benefit from electronic remittance advice is the fact that all adjustments are posted. Without this timely information, you data entry personnel may fail to post the “zero dollar payments,” causing an excessively inflated A/R. This distortion also makes it more challenging so that you can identify denial patterns with the carriers. You may also require 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 Internet connection, you are able to register at these web sites and also have real-time usage of patient insurance information that used to be available only by phone. Including the smallest practice should think about registering to confirm eligibility, request referral authorizations, submit claims, check status, receive remittance advice, download forms and enhance your provider profile. Registration time as well as the educational curve are minimal.

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

Alternately, you could have the choice to utilize 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 must use to submit claims. The cost is normally determined on a per-claim basis and can usually be negotiated, with prices starting around twenty-four cents per claim. While using billing software and a clearinghouse is an effective way to streamline procedures and maximize collections, it is important 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 offered by the clearinghouses.

These systems automatically review electronic claims before they may be sent. They look 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 affords the staff time to correct the claim before it is actually submitted, making it far less likely that the claim will be denied and then need to be resubmitted. Remember, the carriers earn money the more time they can hold onto your payments. A great claim scrubber will help including the playing field. All carriers use their very own version of the claim scrubber once they receive claims on your part.

Using the mandates from Medicare and with all other carriers following suit, you merely do not want not to go electronic. Every aspect of your own practice could be enhanced through the HIPAA standards of electronic data exchange. As the initial investment in hardware, software and training might cost thousands of dollars, the appropriate utilization of the technology virtually guarantees a fast return on the investment.