Taking Full Advantage of Electronic Payor Systems

Electronic payor systems are growing in popularity as the medical billing industry adapts to an increasingly paperless world.  Today’s major payors, such as UnitedHealthcare and Aetna, offer completely electronic solutions for submitting and managing claims, reimbursement, and provider/administrative solutions.  Some of the most well-known of these online systems are OptumNavinetAvaility, and many more.

There are numerous benefits to taking advantage of these systems.  These include, but certainly aren’t limited to:

  • Claim Status:  A number of these electronic solutions, such as Optum and Navinet, allow for identifying claim status (e.g. pending, adjudicated, paid, or denied).  This cuts down on calling time and allows for instant verification of claims receipt and where the claim stands with the payor.  This feature significantly cuts down on time wasted waiting to speak with insurance representatives and provides more substantial evidence of claims receipt and status.
  • Appeals & Claims Corrections:  Gone are the days of paper appeals and claims corrections.  Numerous payors allow for online appeal submission and claims corrections.  Submitting appeals and claims corrections electronically/online allows for better tracking of these submissions and faster processing time.  As a medical billing company, we utilize these functions on a daily basis.  Online access to appeals and claims corrections allows us to see in real-time what the status of these submissions are and if further work is needed.  It also decreases the amount of time spent calling insurance companies and waiting to speak to a representative, who may or may not have the information we need.  It also decreases the potential for “lost mail” or appeals that have been received, but are never even reviewed.
  • Electronic Remittance Advice (ERA):  In today’s world, we no longer have to wait for payments and explanation of benefits to be mailed.  Not only can we receive remittance advice through our online clearinghouse, but we can also obtain the original ERA from the payor’s electronic system.  This is especially useful for finding payments from payors, who may not submit ERAs through your chosen clearinghouse.  Even if ERAs are received through an online clearinghouse, the exact remit information may differ from what the actual payor ERA states.  It is important for medical billers to know where and how to access the original payor remits for purposes of follow-up and appeals.
  • Authorizations: Authorizations can be easily obtained and retrieved from numerous electronic payor systems.  Some systems even allow authorization verification for certain procedure codes.  Various insurance companies require that authorizations be obtained online.  This feature is especially useful for office staff and those responsible for obtaining authorizations.
  • Administrative Functions:  A number of these electronic systems will allow for a certain amount of administrative functions to occur online.  Some offer the ability to update provider information, which must be updated on a regular basis to avoid any delays in processing and payments for a particular provider.  It also allows for important letters and messages to be received that may otherwise take longer when received through mail.  Payor-provider communication is also possible on a number of these systems.  Utilizing this feature allows for more accurate record of communications, less time on the telephone, and quicker turn-around time.

Because most of these services are readily available and relatively easy to use, there really is no excuse for a medical billing team to not use them.  However, we still continue to encounter office staff, providers, and medical billing teams that do not utilize these systems to their fullest potential or at all.  This is true for large practices and small practices alike.  Avoidance of electronic payor systems not only wastes valuable time and resources (e.g. reimbursement), but it also increases the risk for not addressing follow-up in a timely fashion.

At MedPro Services, our staff is highly-aware of numerous electronic payor systems and will use them to the highest potential possible.  We have had incredible success with addressing appeals, finding claim status, correcting claims information, retrieving authorizations, communicating with payors, and updating provider information while utilizing these systems.  You can find out more about our relationship with a number of electronic payor systems here.

Is Your Data Entry Team Working for You?

The very first step in successful medical billing is having a reliable, educated data entry team.  Data entry is the first point at which the claims process begins for medical practices and is, arguably, one of the most important aspects of medical billing.  A medical billing team must have proven accuracy and extensive knowledge of the data entry process because without these things the practice runs of the risk of lost revenue and the potential for failure.

A poorly motivated, under or improperly educated, and inadequately trained data entry team is destined to make costly errors, resulting in huge initial revenue losses for the practice.  While most of these errors can be fixed during follow-up, it is best to avoid data entry errors in the first place because additional work does equal additional costs.  From my experience in medical billing, there are two main types of data entry errors:

  • Demographic errors.  Incorrectly entered data, such as names, insurance numbers, and dates of birth, can result in insurance denials, which can delay payment and result in additional work and resources.  To avoid such errors, have patient demographics prepared electronically, as handwriting is often difficult to read.  Require that the data entry team check all demographic information at least once before charges are entered.  Provide clear copies of patient identification and insurance cards (both the front and the back).  Having an intuitive clearinghouse, such as the Zirmed, may help to stop any of these errors from even reaching payors.
  • Coding errors.  Far too often, data entry errors occur at the time of charge entry.  This is most likely the result of having poorly trained and inadequately educated data entry clerks.  I want to emphasize that medical billing and coding certification does NOT equate expertise in medical billing.  Just because an employee has the credentials does not mean that he or she is a skilled medical billing expert.  Data entry in medical billing is not an easy trade and is a position that requires a strong skill set in the task at hand.  Because of the complicated nature of medical billing, charge entry goes beyond entering whatever information is presented on the superbill.  Providers make mistakes and even though most providers have extensive knowledge in medical billing, superbill errors still occur.  Ultimately, it is the responsibility of the medical billing team to ensure that all claims are being billed correctly and that charges are not simply copied from the superbill.  This skill takes training, education, and thought.  Some common coding errors are: missed or incorrectly used modifiers, inappropriate procedure codes, incorrectly coded diagnoses, place of service errors, and bundling errors.  Data entry clerks must be knowledgeable on claims coding guidelines.  This also includes billing appropriately, even when reimbursement will not be likely.  Coding charges incorrectly just to obtain reimbursement is illegal and could result in auditing.  As a general rule of thumb, provide the medical billing team with the medical reports, so that greater specificity and accuracy can be made when billing out charges.

MedPro Services’ data entry team is comprised of knowledgeable, highly educated staff with extensive expertise in the field.  We take the time to properly train our team on claims coding guidelines and ensure that all checks and balances are in place prior to claims submission.  As a team, we strive for continued education and obtaining current knowledge of claims coding guidelines.  Our staff is highly motivated in obtaining top revenue for our clients because if our providers are losing money, then so are we.  For more information on our data entry services, please visit the data entry section of our website.

MedPro Services also offers consulting.  Our consultation services can help you determine if you are getting the best possible outcomes from your current medical billing department or company and can offer insights into potential areas of improvement, particularly in areas of data entry.  For more information on our consulting services, please visit our dedicated Consultation page.

Appeals Best Practices

Providers and medical billers are well-aware that insurance companies will not always pay every claim for the agreed upon rate and for reasons that vary across the board.  When denials or underpayments do occur, it is best practice to first identify if the claims issue needs appealing.  Because appealing is a lengthy and sometimes difficult process, it should be used as one of the final options in basic claims follow-up.  Prior to appealing, the following should be considered:

  • Correct billing:  Commonly, claims denials are the result of data entry errors.  Humans make mistakes and in an industry that relies on minimal human error to be successful, denials based on human error are, unfortunately, not uncommon.  Before appealing a claims denial, determine if the claim was billed cleanly and correctly the first time.  Common data entry denials might include errors in patient insurance information, bundling denials resulting from incorrect modifier usage, or missing information (e.g. referring doctor, accident/injury date, quantity).  Some questions to consider would be: Were the appropriate modifiers used?; Is there a mismatch between the CPT and diagnosis used?; Is any basic patient information missing on the claim?
  • CPT guidelines:  Following CPT guidelines is not always easy to accomplish.  Currently, insurance companies are not required to follow nationally recognized guidelines, such as CMS guidelines, making claims denials all the more difficult to bill cleanly initially and sometimes to appeal.  Even if correct CMS guidelines are followed when initially billing, sometimes insurance companies do not follow these guidelines.  If you are certain that a claim was billed correctly initially, then check the insurance payor’s provider billing or administrative guide.  These guides are usually available online.  If they are not, promptly request one from the carrier.
  • Payor/Provider contract:  Contracting with an insurance company sometimes requires that certain services will be paid at a specific rate and/or may not be billable at all.  Determine that contracted services are being billed and are being billed appropriately.  If contractual procedures are not being followed, then an appeal may not be possible.  It is important for the provider and medical biller to be aware of contractual requirements as well as contracted payor fee schedules to determine that the payor, as well as the provider, are following the requirements set forth by the contract.

When it is determined that an appeal is necessary, then the appeal should be completed promptly and correctly.  The appeals process varies from carrier-to-carrier, so your medical billing company should be well-versed in the appeals processes of common insurance carriers, such as UnitedHealthcare, Aetna, BlueCross and BlueShield (may vary by state), and Medicare (exact process may vary based on the medicare handler).

Most insurance carriers have a standard appeal time frame.  For some, it could be as soon as 45 days after the denial is received.  For others, it could up to a year.  Still for some, there may not even be a timely appeals filing limit.  It truly varies based on the payor.

The exact appeals process may also vary based on the carrier.  As of 2017, numerous insurance carriers, such as UnitedHealthcare and some Medicare handlers, offer the ability to appeal and monitor appeals online.  If an online/electronic means for filing a appeals is available, then the provider or medical biller should absolutely use this method to file an appeal.  However, even in our modern era, some insurance companies still require appeals to be faxed or mailed, making appeal tracking much more difficult, costly, and timely.  If an appeal is filed via fax or mail, your medical biller should follow-up within seven days of filing to ensure that the appeal was received and what the status of the appeal is.  Always maintain a “paper trail,” collecting reference numbers for every call, appeal document tracking numbers, and documenting all conversations with representatives, ensuring that names and employee id’s are documented.  Most insurance companies will have a timeframe for when an appeal will be complete.  The medical biller should continuously follow-up to determine if an appeal is being processed within that given timeframe.  Finally, copies of appeals should be kept for future reference in a secure location, such as a secure server or on a secure, HIPAA compliant online document storage solution.

The above information on appeals best practices are put forth by MedPro Services.  Our team follows these procedures and more, ensuring that our providers are getting paid on time and for what they are owed.  For more information on our A/R recovery and appeals solutions, visit our site here.

Welcome to the New MedPro Website

Over the past few months, we have been working on crafting a new and improved site, which details the services we provide and who we are as a team.  At MedPro Services, we pride ourselves not only in the quality of service we provide, but also in the personal touch that we can provide our clients.  We think that the new website provides more insight into who we are and what we do.

The new site highlights numerous categories, some of which are the actual services which we provide.  The following are some of the most commonly requested services:

  • Data Entry:  We pride ourselves in the accuracy and quality of our data entry services.  Data entry usually begins with demographic entry, at which point we ensure that all patient demographic information is accurate and current.  Our skilled charge entry team is knowledgable in current CMS, AMA, and ACA billing guidelines and incorporates this knowledge when entering client charges.  Not only are we familiar with various EMR/EHR solutions, but our billing software also has the capability of interfacing with numerous EMR/EHR platforms.  We also post payments for our clients and are experienced in utilizing electronic payment solutions (e.g. Change Healthcare, PaySpan) and our state-of-the-art clearinghouse, Zirmed.  At MedPro Services, it is our belief that data entry is the first step in ensuring our clients are receiving the best possible outcomes and highest revenue possible.
  • Clean ClaimsOur team is comprised of highly-skilled claims representatives, who are aware of the multiple means for submitting claims, the filing preferences of various insurance carriers, and the limits for timely filing, an aspect of insurance claims filing that varies from carrier-to-carrier.  We use a multi-tiered process for scrubbing claims and ensuring that claims are submitted cleanly upon first submission.
  • A/R Recovery: Something that sets us apart from the competition is our focus on A/R recovery.  Each claim, no matter the dollar amount, is important to us and to our clients.  If A/R is neglected, then the client is missing out on high potentials for revenue.  Some of our competitors strive for “easy money,” which is the revenue obtained by simply submitting claims and not following-up on those that did not pay.  This method results in high-profit margins for the billing service, but severely affects the client’s bottom line.  At MedPro, we follow up on all claims, all the time and have a proven record of increasing client revenue by as much as 30% within the first 3-6 months.
  • Credentialing & ConsultingBeyond the traditional medical billing services, we provide credentialing and consulting services as well.  Credentialing is one of the more difficult aspects of running a practice.  It is time consuming, requires detail and skill, and can be daunting for those unfamiliar with the process.  Our in-house credentialing expert is aware of the credentialing processes for numerous payors and is prepared to help clients credential as swiftly as possible to avoid any timely payment issues.  For those interested in reviewing their current billing company, how their practice is performing overall, or wanting specific reports (e.g. collection ratio, days in A/R, payor insurance mix), we also offer consulting services.
  • Online Payment PortalWe offer online payment solutions through our clearinghouse, Zirmed.  This payment portal has given some of our clients the ability to collect patient payments quickly and efficiently, while allowing our team to post payments as soon as they are received. This solution also allows patients to pay online during times at which our office is closed, something that both patients and clients love.

Our new site also highlights our current team.  We have included a “Meet the Staff” portion of this site because we believe it is important for our current and future clients to know who we are as people.  Sometimes it helps to put a name to a face and allows even more of a personal touch.  We encourage you to check out our “Meet the Staff” and get to know each of us a little better.