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.