Unfortunately, there has been a great deal of inconsistency in the implementation of HIPAA’s ANSI standard among electronic carriers – the entities that process your electronic claims. As a result, electronic billing has increased in complexity, as opposed to being simplified, and this costs you in two ways:

· As technology vendors struggle to incorporate the vagaries of each carrier, they inevitably transfer their implementation costs to you.

· A myriad of choices are now available to you to submit your claims electronically: clearinghouses, web services, direct submission packages, etc. – each with its own set of benefits and idiosyncrasies. This imposes an administrative burden on your billing staff.

There is a way for you to gain control, however, and that is by utilizing best practices for ensuring an efficient electronic billing process. An efficient e-billing process leads to a faster reimbursement turnaround, as it reduces billing errors, increases claim submission throughput, and improves claim acceptance rates. It ensures that no claims are forgotten in the billing cycle, and receivables are kept at their lowest.

Choose between single entity and best-of-breed for submitting electronic claims.

You can either submit all your electronic claims to a single entity, such as a clearinghouse, or use a "best-of-breed" approach, in which you use a combination of clearinghouses and direct submission packages. At the technical level, your billing software produces an electronic file that contains the claims you would like to submit. The question is: Where to send this file?

Direct submission packages are usually available as add-on components to your billing software, although sometimes they are offered directly by the carrier. The billing software produces a separate file for each carrier: one file for Medicare, one for Blue Cross, and one for commercial claims to a clearinghouse. You then submit the Medicare file to the Medicare carrier, the Blue Cross file to the Blue Cross carrier, and the third file to the clearinghouse.

Typically, the advantages of the best-of-breed approach are that you are able to submit claims directly to the payer without a middleman, and you do not have to pay recurring fees.

However, it also has a number of hidden costs. You must purchase the additional components, and this can impact your software support fees. It also places a further burden on your billing staff, which is forced to remember multiple file names, transmission methods (dial-up, BBS, ftp, web), and login/password combinations; which payers are preferred versus non-preferred (the latter means that extra fees will apply for claims submission); and to download and interpret each carrier’s response reports. This can be time consuming and confusing, and can lead to increased billing errors, and therefore, denied claims.

The advantage of submitting claims to a single entity is simplicity – your software produces just one file that is sent to one place. There is usually a lower upfront cost as well. But the problem with this approach is the recurring costs you will incur, which can add up in the long run. You typically pay per-claim and/or monthly per-provider fees. This is on top of the support fees you may pay for the billing software.

So, how to resolve the two? Figure out the costs for each. For the best-of-breed approach, consider the cost of each add-on component, and the increased cost of software support. For the single entity approach, figure out your average monthly claim volume and multiply it by the applicable fees. These are the direct costs. Now we must consider the time-cost of the billing staff using each method. With the best-of-breed approach, the staff is spending time managing multiple submission methods. You must compare the time saved by your staff using the single entity solution against the recurring cost of submitting to a single entity.

Compare these costs over a specific period of time. A good rule of thumb is to use the number of years you plan to use the billing software.

Be sure to have proper IDs for e-billing.

Know the Medicare ID for each facility at which you provide service.

Each provider in your practice is assigned a number by each payer. Be sure to have the correct rendering provider IDs.

Make sure you have entered the UPINs of all your referring physicians into your billing software.

If you submit claims to a clearinghouse, download a copy of its payer list, find the payers to whom you submit claims, and enter the corresponding payer IDs into your billing software.

Obtain authorization information at the time of making the appointment.

Don’t wait until it’s time to submit your claims to obtain authorization information. Ask your patients to fax over the referral prior to the appointment. If that is not possible, ask if the patient’s primary physician will send the referral to your office, and if so, remind the patient to make sure that this is done prior to the appointment. If nothing else, ask the patient to bring it when he or she arrives for the appointment.

Collecting authorization information prior to the appointment frees the front desk staff to concentrate on patients waiting to be seen in your office, and the billing staff to focus on sending out clean claims with all the appropriate information.

Verify eligibility prior to the visit. Do it electronically.

Along the same lines, verify the patient’s insurance eligibility prior to the appointment. This saves time when the patient walks in, and saves the patient and your staff from an embarrassing situation in your office if the patient’s eligibility is denied for any reason.

Preferably, check eligibility online. More and more payers are offering this service through their web sites. Alternatively, if you have a high volume of patients, you can contract with a clearinghouse or web service to perform eligibility checks on a batch of patients. There are typically fees associated with such a service, though.

Prevent charges from slipping through the cracks by running a missing charges report.

If your billing software provides it, run a daily report of missing charges – super bills that were printed with no corresponding charges entered.

Check your claims for missing information.

Does your billing software perform an edit prior to the submission of electronic claims? If so, be sure to run it. If not, look into it. It can save you hundreds, if not thousands, in reduced billing errors, and can significantly boost your claims acceptance rate.

Make sure you actually send your electronic claims file!

Once your billing software creates the file you’re not done! Be sure to actually send the file to your electronic carrier. And make sure you’re sending the correct file!

Always, always, always obtain a report after sending your file!

Always.

The HIPAA ANSI standard has mandated that electronic carriers must provide you with a report commonly referred to as the "277 report." This report informs you whether your claims have been accepted for further processing or rejected (and why). Your billing software should provide you with a list of claims submitted in the electronic claims file. You need to match the 277 report to this list to make sure the carrier received all your claims.

Follow up! Diligently track and manage your billing/reimbursement cycle.

A good billing system should provide you with the means to manage your billing cycle. For example, it should enable you to quickly determine how many claims you have submitted during a given period, and how many are left to be paid.

An Insurance Payment Tracer is a powerful tool offered by some billing systems to track the status of claims that have seemingly "disappeared." It is a form letter that you can send to the insurance company asking for status on a claim you have submitted. The tracer clearly states the name of your practice, the rendering provider’s name, the patient’s name and insurance ID, and details of the claim submitted, such as the dates of service, procedures, diagnoses, and amounts charged. Best of all, the tracer has a "return receipt" that the insurance company can fill out and send back. The return receipt asks for the status of the claim, and – most importantly – the name, phone number and signature of a representative of the insurance company.

The insurance payment tracer enables you to hold insurance companies accountable, and provides you with vital documentation of your collection efforts.

Run an unbilled charges report to identify unbilled claims.

This report will provide you with a list of claims that have not yet been billed. If your billing software provides it, be sure to run this report regularly.

The more efficient your billing processes, the lower your administrative overhead, and the higher your claims acceptance rates. This translates into increased cash flow for you.