The passage of the Health Information Portability and Accountability Act (HIPAA) in 1996 standardized electronic claims for the healthcare industry. This submission method has been widely adopted and was used by more than 92 percent of healthcare providers in the United States in 2013. This trend clearly shows the great majority of providers recognize the superior accuracy, efficiency and speed of electronic submissions over manual methods. However, obtaining the maximum benefits from electronic claims requires providers to follow a number of best practices in the preparation, submission and follow-up phases of this process.
Preparation Before Starting the Claim Processing
Medical practices must verify a patient’s insurance coverage for the services they require before each appointment. The most accurate coding in the world won’t help a practice obtain payment if the service isn’t covered or the patient’s insurance has lapsed. A carrier may deny the claims if the provider fails to fulfill the health plan’s prior authorization requirements even if the patient is eligible for the treatment. Practices must therefore remain aware of the services that require prior authorization and complete the necessary steps before treating the patient.
Clinical documentation that justifies the coded services is also essential for making successful claims and maximizing the practice’s revenue. Accurate data entry during registration is also part of this process, especially the patient’s demographic information and insurance member number. Mistakes in these areas routinely result in claim denials, necessitating expensive re-submissions. Practices must also meet submission deadlines to receive payment in a timely manner.
Final Check Before Claim Submission
Accurate and specific coding is one of the most important parts of claims submission, which primarily include Current Procedural Terminology (CPT) and International Statistical Classification of Diseases (ICD) codes. The most current version of ICD codes is ICD-10, which went into effect in 2015. Practices should also compare their appointment schedule to insurance claims when billing healthcare plants. This step will ensure the required documentation is submitted for all patient services that were performed.
Claims attachments are also becoming increasingly important for successful claims, especially for certain procedures. A practice should learn which procedures are likely to require additional documentation as it becomes familiar with each health plan’s requirements. A practice can thus shorten the claims process by proactively submitting the required attachments with the initial submission, rather than waiting for the carrier to request it.
Scrubbing or Pre Audit After Claim Submission
Additional steps after the claims submission are often required before a practice can expect to receive payment for its services. Many practice management vendors offer pre-audit, or scrubbing, services to identify claims errors before the claim formally enters the health plan's adjudication system. Healthcare providers should use these services to proactively correct errors and minimize payment delays. Furthermore, pre-audit reviews allow practices to correct their procedures and retrain personnel, thus preventing similar errors on future claims.
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Practices don’t typically know when an insurer has received a claim, which can result in payment delays. Some health plans do acknowledge receipts, although this isn't currently a legal requirement. Practices should therefore follow-up on claims submittals by using an electronic claim status inquiry to verify the receipt of a submitted claim. Health plans are required to respond to such a request, allowing practices to track the claim through the entire adjudication process.
Electronic claims have already increased the operational efficiency of medical practices. Healthcare providers should take full advantage of this capability by incorporating the above tips throughout all phases of the medical billing process. Additional opportunities for improving a practice’s efficiency include the electronic coordination of multiple claims and adjudication of claims in real time.
M-Scribe Technologies, LLC is a national leader in medical claims billing that can help your back office with coding and billing issues such as ICD-10 readiness. Call us at 770-666-0470 or email firstname.lastname@example.org to learn how we can help meet your practice’s needs.