Electronic Health Care Claims: What You Need To Know

 Many practitioners are concerned about being paid on time and correctly. One tool that practitioners are increasingly using to help with claim reimbursement is electronic claim submission. Practitioners are discovering that electronically transmitting insurance claims to carriers, managed care companies, and other health care payers can improve cash flow and streamline billing operations. The expectation that an increasing number of insurers will require electronic claim submission in an effort to cut costs has also contributed to the trend toward greater use of electronic health care claims. Medicare payment policies, which require hospitals and clinics to submit all Medicare claims electronically, have also aided the trend. The Health Insurance Portability and Accountability Act has also contributed to the shift toward electronic claims (HIPAA). The HIPAA Transaction Rule required the use of standardized formats for electronic claim transmission in order to facilitate the electronic exchange of health care payment information. This article outlines the fundamentals of electronic medical claims submission to assist the practitioner in learning more about - and making the transition to - this increasingly popular reimbursement option.

Why Should Claims Be Filed Electronically?

Filing claims electronically has a number of advantages, including:-

• Reduce interruptions to your cash flow. Electronically submitted claims are processed more quickly, resulting in faster payment.

• Keep track of the status of your claims. Verify the status of your submitted claims at any time of day or night using a secure Internet connection.

• Reduce claim rejections by increasing accuracy. While paper claims are frequently rejected due to inaccuracies, omissions, or other issues, electronically submitting claims can result in fewer lost or incomplete claims. You can have an electronic clearinghouse check your claims for accuracy before submitting them to carriers, and they will promptly return any missing or incorrect information to you before forwarding them to the payer.

• Reduce your paperwork. Electronic claim submission eliminates the need to fill out and store paper claims, assisting in the streamlining of the best medical billing software procedures and the simplification of record keeping.

• Reduce overhead costs and employee time. Claims submitted electronically save clerical time and money spent on processing, mailing, resubmitting, and tracking the status of paper claims, allowing your administrative staff to focus on other important tasks.

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How Do You File Electronic Claims?

There are numerous options and providers for submitting claims electronically. The following are some of the fundamental characteristics of full-service and self-service electronic claims:-

"Full-service" Electronic Claims:- A third party - usually a billing service - files electronic health care claims on behalf of a practitioner. The practitioner is only required to send basic patient and service information to the billing service, which then creates and submits the claim to the appropriate insurer or a health care claims clearinghouse. What is the price? As payment for its services, the billing service frequently retains a percentage of the total claim amount. The percentage retained is frequently determined by the type of services provided and can range from 4 to 15% of the total claim amount.

"Self-service" Electronic Claims:- Self-service electronic claims are developed and submitted directly to a third-party payer or health care claims clearinghouse by a practitioner. Practitioners who only submit claims to one or two payers may choose to submit their claims directly to the payer using proprietary software provided by the payer. Practitioners who submit claims to a variety of third-party payers, on the other hand, may find it more convenient to submit claims to a single clearinghouse, where the claims are classified, arranged, looked for perfection, and passed on to the suitable payer. There are several options for submitting claims to a clearinghouse, including:-

• Direct file upload. Some practitioners submit claims to a clearinghouse using their practice management software. The practice management software generates an electronic file containing the claims to be processed, which is then transmitted to the clearinghouse via a secure connection over the phone or the Internet.

• Data entry is done directly. Practitioners who are uncomfortable or unable to use their practice management software to submit claims can still reap the benefits of doing so electronically. Using direct data entry, the practitioner or a member of his or her staff logs into a clearinghouse via a secure Internet connection, enters the provider, patient, and claim information into a formatted web page - frequently an electronic version of the HCFA 1500 - and submits the claim for processing. The clearinghouse can save the patient, provider, and claim information in a secure system so that the practitioner does not have to reenter it all if he or she files similar claims in the future. Charting, prescription management, electronic prescription transmission, medical billing, imaging, and scanning integration, among other clinical and service record maintenance and access features, are some of the core features available in practice fusion EHR.

Additional self-service claim submission options may be available for a fee, allowing practitioners to perform functions such as:-

• Examine insurance information such as patient eligibility, plan details, and copayments.

• Convert patient statements into an electronic format that can be downloaded into practice management software.

• Check online for referrals, pre-certifications, and authorizations.

• Receive electronic Remittance Advice (ERA) and Explanation of Benefit (EOB) statements from participating payers to determine when and for how much a claim is paid.

For solo practitioners and small practices, self-service billing is often less expensive than using a full-service billing service, and it gives the practitioner more control over the sensitive personal information contained in a claim.

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