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Make Your Electronic Claims More Efficient

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03/16/2016

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Tips for Before, During, and After Claim Submission

By the American Medical Association


In order to improve the efficiency of physicians' healthcare claims submissions, HIPAA mandated use of a standardized electronic claim throughout the healthcare industry. Since then, the standardized electronic claim has been widely adopted throughout the industry, with over 92 percent of health plans and providers utilizing the transaction in 2013.1 Such widespread adoption clearly indicates that providers and health plans recognize that automated claims can improve the speed, efficiency, and accuracy of claim processing. To further claims processing, the AMA offers the following tips for providers to follow before, during, and after claim submission.

Prior to Claim Submission: Be Prepared
To get the most out of electronic claims, the AMA recommends that physician practices take the following steps to ensure successful claims submission:

  • Verify patient eligibility before every appointment. In order to receive payment for a particular service, a provider must be sure that the patient has valid insurance and is eligible to receive the treatment. Even the most specific and accurate coding cannot help a physician obtain payment if the patient's coverage has lapsed or a service is not covered by the health plan in question. Checking eligibility prior to every patient appointment is therefore the essential first step in the claim revenue cycle.
     
  • Perform quality documentation. A successful claim should be adequately supported by clinical documentation justifying the level of service coded and billed to the health plan. Consistent, quality documentation will help maximize practice revenue by enabling a physician to establish the need for any higher level of service.
     
  • Complete prior authorization if necessary. Even if a patient is eligible for an appropriate medical treatment, physician claims may be denied if the practice did not fulfill a health plan's prior authorization requirements. As a result, practices need to be aware of which services require prior authorization and complete all steps in advance of patient care.
     
  • Be aware of deadlines. In order to receive proper payment in a timely manner, practices need to be aware of and meticulously meet all deadlines for health plan claim submission.
     
  • Ensure accurate data entry. Although it may seem obvious, practices should take steps to avoid data entry errors. Basic data entry mistakes during the registration process, such as errors in insurance member numbers or patient demographic information, can mean claim denials, which would necessitate data recollection, re-entry, and resubmission.

Claim Submission: Tips for Successfully Completing the Electronic Claim Process
In order to facilitate efficient billing, the AMA offers the following tips to help practices get the most out of electronic claims submission:

  • Code with maximum accuracy and specificity. Correct and optimal use of Current Procedural Terminology (CPT) and ICD-10 codes ensures proper payment for provided services. Visit ama-assn.org/go/cpt to access further information about the procedure codes used to bill health plans for patient care. Practices can obtain further information about ICD-10 codes, which were mandated for use effective October 1, 2015, at ama-assn.org/go/icd-10.
     
  • Compare appointment schedule to claims. In the heat of a physician practice's busy schedule, it can be easy to overlook a particular patient service when completing health plan billing. In order to verify that all claims have been properly submitted for each of the physician's patients, practices should reference their appointment schedule when submitting claims. This will enable staff to ensure that all patient services performed throughout the day have been properly submitted for payment to health plans.
     
  • Include claims attachments. As practices become familiar with health plan payment policies and requirements, they often become aware of standard documentation requests associated with particular procedures. In order to speed up the claim process, the AMA encourages practices to proactively submit attachments with the appropriate documentation at the time of claim submission. This will eliminate the additional time needed for a health plan to subsequently request the information.

Post Submission: Follow-Up on Electronic Claims
Even after a practice has submitted a claim, there may still be work to do. Physician practices can take these additional steps following claim submission to maximize efficiency:

  • Utilize pre-audit/claim scrubbing services. Many clearinghouses and practice management system vendors offer claim pre-audit or claim "scrubbing" capabilities to catch errors before the claim is formally accepted into a health plan's adjudication system. The AMA recommends that providers take advantage of these capabilities, which allow practices to rework errors immediately and prevent payment delays. Additionally, this enables practices to learn from issues caught in pre-audit review and take subsequent steps to ensure that appropriate staff members are trained on fixing the issue.
     
  • Track submitted claims using the electronic claim status request transaction. Typically, practices do not know if their claim has been received by a health plan until it is paid, pended, or rejected. While some health plans and clearinghouses offer an acknowledgement transaction to confirm that a claim has been received, this is not currently required by law. In order to proactively track claims, providers are encouraged to utilize an electronic claim status inquiry to confirm receipt of submitted claims, as well as to determine claim status. Health plans are required by law to respond to a status request, so practices should utilize this transaction to help efficiently track the health plan receipt and adjudication of claims.

While the electronic claims process has already resulted in significant efficiency throughout the healthcare industry, practices can maximize their savings by incorporating the preceding tips into their claims submission procedures. Practices may also consider pursuing further automation through electronic submission of secondary and tertiary claims (coordination of benefits) and real-time adjudication, which can offer additional practice efficiencies. Visit ama-assn.org/go/claims for additional information on how to usher in savings through claims automation.


Resources
1 2014 CAQH Index™ Electronic Administrative Transaction Adoption and Savings, www.caqh.org/sites/default/files/explorations/index/report/2014Index.pdf.

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