In an effort to combat declining reimbursement and improve office cash flow, many physicians are shifting away from time-consuming paper claims toward the convenience of a computerized billing system. Such a system allows a physician to electronically chart documentation, post test results, and submit reimbursement claims, while providing the efficiency, expediency, accountability and oversight that could never have been possible via the paper process.
Understanding the steps to properly submit electronic claims is important and key to combating reporting errors that may arise, as well as preventing denied reimbursement.
Understanding the Process
There are several steps that must be followed to initialize electronic billing. First, the physician must file an enrollment form with the carrier. Individual insurers may have a variety of compatible software and hardware requirements necessary for claims submission.
Second, when submitting a claim the physician must specify the submission format being used, such as the National Standard Format or the American National Standard Institute Format. The type and speed of the modem for sending the claim also must be specified and be compatible with the insurer’s requirements.
Once the enrollment forms are processed, the physician will receive identification symbols and a password for accessing the insurer’s database. The electronic claims software, such as Medicare-compatible Paperless Claims Express or ACCESSplus®, must be loaded with the files and directories needed for claims submission. The type and place of service, as well as provider information must be entered and claims must be formatted according to the individual carrier’s requirements, including such information as provider name, receiver identification, patient demographics, and secondary claims requests.
Upon successful log-in, the physician will be prompted to transfer data files to the insurer. Confirmation of receipt can be obtained quickly after data transmission is complete. In fact, the Health Care Financing Administration mandates acknowledgment of receipt, timely payment, and rapid notification of uninterpretable data transmission.
Fewer than half the states have “prompt pay” statutes; however, those with payment regulations require payment of “clean claims” within 15-60 days of receipt. For late payments, interest may range from 8-25 percent annually.
Common Pitfalls in Electronic Billing
Although electronic submission vastly improves processing time and provides rapid confirmation of receipt, the transmitted data must be accurate for successful claims processing. Simple factors that must be accurately entered include patient demographic data and identification numbers. The transposition of such numbers is a common mistake that often results in denied reimbursement.
Improper formatting also is a common reason why electronic claims are denied. For example, some carriers request bilateral procedures to be entered twice with the second code appended with the -50 modifier, whereas others require a single code entered with the -50 modifier accompanied by “two units.” Procedures should be listed in descending order of value to prevent application of the multiple procedure rule to higher valued services.
Additional data that must be submitted includes place of service and type of service codes. Some carriers have already linked various services to their appropriate location. Appropriate diagnostic ICD-9 codes must be linked to the physician service CPT codes. A variety of software programs have been developed for the insurers to identify mismatch of diagnostic and procedural codes.
For example, Medicare contracted with regional carrier Administar to create and maintain a database of coding edits to identify incompatible codes, as well as inapproppriate unbundling of codes.
Finally, the name and unique provider identification number of the requesting physician must accompany evaluation and management codes describing consultative services.
Despite the advantages of electronic claim submission, several procedural services can’t be submitted using this format. For example, auto insurance claims usually require submission of the operative note along with the paper claim. Similarly, workman’s compensation claims usually require a paper claim with a copy of the office note or operative dictation.
Advantages Over Traditional Paper Claims
Electronic claims submission offers physicians numerous advantages over traditional paper claims, including adequate confirmation of claims receipt, expediency in processing charges, limited transcription errors and data entry errors, and reduced delays in payment from “lost” paper claims. Cheaper claims processing also has prompted insurers to encourage electronic submissions by offering rapid payment for clean claims.
Although more rapid reimbursement can be achieved, accurate coding and data entry remains imperative, particularly because software programs can identify mismatched coding pairs.
Gregory Przybylski, MD, is an Assistant Professor of Neurosurgery at Thomas Jefferson Medical College and a faculty member for the AANS Foundations Reimbursement PDP courses.
Gregory Przybylski, MD, is an Assistant Professor of Neurosurgery at Thomas Jefferson Medical College and a faculty member for the AANS Foundations Reimbursement PDP courses.