There's no doubt that electronic data interchange has streamlined the health insurance claims process, especially in an environment of ever-increasing medical necessity documentation needs. For most practices, EDI results in faster reimbursement, fewer rejections, less staff time reworking claims, and an overall boost to ROI.
That said, however, EDI is not without its quirks. Here's a look at some common EDI rejections and how to resolve them in a timely manner
Who do I contact when I have an issue with EDI submissions?
In general, your EDI vendor is responsible for EDI software and submission capabilities, so it should be your first point of contact for issues such as:
- HIPAA file formatting and compliance.
- Problems with connectivity and delivery.
- Not receiving EDI reports.
- EDI reports indicating a problem with software, not with payers.
On the other hand, contact your payer's EDI support desk for the following problems:
- Payer reports and edits.
- Delivery verification.
- Claims filing instructions, enrollment, and testing.
How can I reduce or eliminate electronic claims errors?
Most claims errors can be eliminated with editing or "claims scrubbing" software that detects keystroke errors, ensures current code sets, and permits error correction before claims submission. Find out what processes are available through your EDI vendor—or what steps are taken by your outsourced billing service to ensure clean claims submission, if you are evaluating medical billing services.
What happens if I haven't been reimbursed for electronic claims?
Here's a good step-by-step checklist to resolve unpaid electronic claims:
- Check with your vendor to make sure there were no problems with transmission.
- Check for correct payment indicator and provider number.
- Verify with your vendor that no errors occurred between your PM system and the vendor or payer.
- Verify both your vendor and your staff are up-to-date with error correction systems.
- Ask your EDI vendor to obtain a copy of the payer's acknowledgement to verify the submission was received.
- Contact the payer's EDI help desk to follow up.
How do I reconcile electronic funds transfers?
Compare the EFT check amount and the ERA for accuracy. Find out when payers post transactions to your bank account each week and verify the figures match the EFT and ERA. Contact payers directly if there is a discrepancy.
How do I know if my EDI vendor is delivering files to the payers?
It's extremely important to monitor reports both from your vendor and payers on a daily basis to ensure files are both delivered and received. If you still have questions, follow these steps:
- Verify that your vendor's file pickup and delivery schedule for your office is on track. Remember that in many cases, files received after 4 pm or 5 pm will be processed on the next business day.
- Make sure that there are no connectivity issues with your vendor that may have delayed delivery.
- Contact your payer directly with vendor ID number and date of submission to verify the claim has been received.
Who is responsible for informing me of any payer changes that affect my EDI submissions?
Most payers work closely with their trading partners to give them advance notice of any changes in the EDI protocols and procedures. Your EDI vendor is responsible for keeping you up to date on any system notifications that impact your practice.
- Contact your vendor and establish a routine schedule for delivering any payer notices that affect you. Make sure that the notices are received in a format your office can accept.
- Check payer websites for EDI news and updates that might impact your practice.
If you have questions about EDI, electronic claims management, and medical billing software—and how they are affecting your revenue cycle management, contact the billing experts at M-Scribe today for a free consultation.