For many practitioners, being paid on time and appropriately is their top priority. One technology that professionals are adopting more and more to simplify the claim reimbursement process is electronic claim submission.
The electronic transmission of insurance claims to carriers, managed care organisations, and other healthcare payers is helping practitioners increase their cash flow and improve the efficiency of their billing processes.
The assumption that an increasing number of insurers will require electronic claim filing in an effort to save costs has also contributed to the trend toward wider use of electronic claims. The movement has also been supported by Medicare payment procedures, which mandate that all Medicare claims be submitted electronically by hospitals and clinics.
The Health Insurance Portability and Accountability Act has also prompted the switch to electronic claims (HIPAA). The HIPAA Transaction Rule required the use of standardised formats for electronic claim transmission in order to facilitate the exchange of health care payment information electronically.
The "HIPAA compliance" section of APApractice.org has more details about the implications of the HIPAA Transaction, Privacy and Security Rules.
This article explains the fundamentals of electronic claim submission to assist practising psychologists in learning more about — and adjusting to — this more common reimbursement choice.
Why Should Claims Be Filed Online?
There are several advantages to filing claims electronically, including:
Keep alterations to your cash flow to a minimum. Electronically submitted claims are processed more quickly, leading to quicker payment.
Monitor the status of a claim. Whenever you want, day or night, use a secure Internet connection to check the status of your submitted claims.
Reduce claim denials and improve accuracy. While errors, omissions, and other issues frequently cause paper claims to be denied, electronically submitting claims can lead to a reduction in lost or incomplete claims.
You have the option of having an electronic clearinghouse verify your claims for completeness before sending them to carriers. If any information is missing or incorrect, the clearinghouse will swiftly return the claims to you before sending them on to the payer.
Reduce your paperwork. By eliminating the need to fill out and store paper claims, electronic claim submission helps to simplify your billing processes and record keeping.
Reduce labour costs and staff time. By submitting claims electronically, you can free up your administrative staff to handle other crucial tasks by saving time and money on the administrative tasks of processing, mailing, resubmitting, and tracking the status of paper claims.
How do I submit claims electronically?
There are numerous providers and options available for electronically submitting claims. Some of the fundamental components of both full-service and self-service electronic claims are listed below:
Electronic Claims "Full-service"
Full-service A third party, frequently a billing service, submits electronic claims on a psychologist's behalf. The billing service develops the claim and submits it directly to the relevant insurer or to a health care claims clearinghouse after receiving only the most basic patient and service information from the psychologist.
What is the price? As compensation for its services, the billing agency frequently retains a portion of the entire claim amount. The proportion retained, which can range from 4 to 15% of the overall claim amount, frequently depends on the sorts of services rendered.
Electronic Claims for "Self-service"
A psychologist (or a member of the psychologist's staff) creates and submits self-service electronic claims directly to a third-party payer or health care claims clearinghouse.
Practitioners who only submit claims to one or two third-party payers may choose to submit their claims directly to each payer utilising the payer's proprietary software.
However, practitioners who send claims to a variety of third-party payers frequently find that sending claims to a single clearinghouse—where the claims are sorted, prepared, reviewed for accuracy, and sent to the correct payer—is the most practical option. There are several ways to submit claims to a clearinghouse:
File submission directly: Some doctors send claims to a clearinghouse using their practise management software. The claims-to-be-processed electronic file is created by the practise management software and submitted to the clearinghouse over a secure connection over the phone or internet.
Direct entry of data: The advantages of filing claims online are still available to practitioners who are unable or uncomfortable using their practise management software. The practitioner or a member of their staff enters the provider, patient, and claim information into a formatted webpage — frequently an electronic version of the HCFA 1500 — and submits the claim for processing using direct data entry.
This is done by logging into a clearinghouse using a secure Internet connection. In order to save the practitioner time if they submit similar claims in the future, the clearinghouse can save the patient, provider, and claim information in a secure system.
For an additional fee, additional self-service claim submission tools may be accessible, allowing practitioners to carry out tasks like:
Verify insurance details, including patient eligibility, plan details, and co-pay amounts.
Transform patient statements into an electronic format for practise management software download.
Check online for authorizations, pre-certifications, and referrals.
Receive electronic Explanation of Benefit (EOB) and Electronic Remittance Advice (ERA) statements from participating payers to quickly ascertain when and how much a claim has been paid.