14 Jun Making Electronic Claims More Efficient
The Health Insurance Portability and Accountability Act mandated the use of standardized electronic claims to improve the efficiency of a physicians’ healthcare claims submissions. The standardized electronic claim has been widely adopted in the industry, with more than 92% of health plans and providers using this by 2013. Health plans and physicians recognize the importance of electronic claims submission for the efficiency, speed, and accuracy of claim processing.
Before Claim Submission
The American Medical Association (AMA) has proposed certain guidelines for submitting electronic claims. The following steps will assure successful claims submissions:
- Verify patient eligibility – Before the scheduled office visit, you should verify if the insurance is valid, and if or not the patient can receive the treatment or service. The physician cannot obtain payment if the patient’s insurance coverage has lapsed, or if the service or procedure is not covered by the plan. This involves checking eligibility before for every patient appointment.
- Complete prior authorization – When the patient is eligible for the treatment or service, the physician’s clams may be denied if the office staff does not obtain prior authorization. This requires sending necessary documentation and reason for the service to the health plan for approval.
- Provide quality documentation – For a successful claim, the physician should adequately support the services with clinical documentation. This is used to justify the level of service coded and billed to the health insurance plan. Quality documentation helps maximize practice revenue and enables the physician to establish the need for much higher service levels.
- Be aware of deadlines – To receive proper reimbursement in a timely fashion, the practice and billing specialists should be aware of all deadlines regarding health plan claim submission.
- Provide accurate data entry – The medical practice should take necessary steps to avoid data entry errors. Basic data entry errors during the registration process can mean claim denials. Errors in insurance member numbers or patient demographics could necessitate data recollection, re-entry, and resubmission.
Tips for Successfully Completing the Claims Process
Regarding claim submission, there are things you can do to ensure successful completion of the electronic claims process. This facilitates efficient billing. According to the AMA, you should:
- Code with maximum specificity and accuracy – This involves correct and optimal use of ICD-10 and CPT codes, which ensures proper payment for all services provided. The practice can obtain further information about ICD-10 codes, which were recently put in effect.
- Compare appointment schedule to claims – The physician practice could easily
overlook a particular patient service when billing. For each of the patients, the billing specialist should reference the appointment schedule, which enables staff to make sure all services performed were submitted to the health plan for payment.
- Include claims attachments – As a medical practice becomes familiar with a certain health plan’s policies and requirements, staff members become aware of the standard documentation requests related to individual procedures. The billing specialist can speed up the claim process by submitting attachments with documentation at the time of the claim submission.
Follow-Up on Electronic Claims
After a physician practice has submitted a billing claim, there is still some work to be done. Physician practices and billing specialists will take additional steps to maximize efficiency by:
- Utilizing pre-audit/claim scrubbing services – Many practice management system vendors and clearinghouses offer pre-audit (claim scrubbing” capabilities. These services find errors before the claim is accepted into a health plan’s adjudication system. These services allow the practice to rework errors and prevent payment delays.
- Track submitted claims using status request transaction – Regarding electronic claims, the practice can acknowledge the transaction to confirm the claim has been received. Practices will know when the health plan pays, rejects, or holds a claim.
2014 CAQH Index™ Electronic Administrative Transaction Adoption and Savings, www.caqh.org/sites/default/files/explorations/index/report/2014Index.pdf