Presentation on theme: "Insurance Handbook for the Medical Office"— Presentation transcript:
1 Insurance Handbook for the Medical Office 13th editionChapter 08The Electronic Claim
2 Electronic Claims Submission Overview Lesson 8.1Electronic Claims Submission OverviewDefine electronic data interchange.Summarize the advantages of electronic claim submission.Describe the clearinghouse process that follows after a claim is electronically received.Identify the transactions and code sets to use for insurance claim transmission.State which insurance claim data elements are required or situational for the 837P standard transaction format.
3 Electronic Claims Submission Overview (cont’d) Lesson 8.1Electronic Claims Submission Overview (cont’d)Define a claim attachment, and explain when the electronic standards will be mandated.Compare and contrast standard unique provider identifiers, health plan identifiers, and patient identifiers.Describe necessary components when adopting a practice management system.Describe the use of patient encounter forms and scannable encounter forms in electronic claim submission.
4 Electronic Data Interchange Used for transmission of health insurance claimsTransmitted data is encryptedImproves efficiency of claims submissionsWhat is “EDI”? (The process by which understandable data items are sent back and forth via computer linkages between two or more entities that function alternatively as sender and receiver.)What is “encryption”? (To assign a code to represent data, for security purposes.)
5 Advantages of Electronic Claim Submission No signatures or stampsNo searching for an insurance carrier’s addressNo postage costs or trips to post officeNo need to store or file claim formsElectronic claims leave an audit trailImproved cash flowQuicker processing time and paymentReduced overhead and labor costsElectronic claims are becoming the way business is done; it is efficient and reduces overhead.Errors are reduced partly by computers with prompts to guide processors through a complete and accurate claim, and also by an online error-edit process that flags mistakes immediately so they can be fixed before filing.Define “audit trail.” (A chronological record of submitted data that can be traced to the source to determine the place of origin.)Ask students if anyone has worked with coding. What were some of the challenges? (Answers will vary.)
6 Clearinghouses Claims are checked electronically Claims with missing/incorrect information are rejectedRejected claims are sent back to the provider with a reportBatches of acceptable claims are sent to the appropriate payerCorrected claims are reprocessedWhat is a “clearinghouse”? (An entity that receives the electronic transmission of claims (EDI) from the healthcare provider’s office and translates it into a standard format prescribed in HIPAA regulations.)A clearinghouse should separate claims by carrier, perform software edits to check for errors, and transmit claims electronically to the correct payer.
7 Clearinghouses Advantages of a clearinghouse Translation of various formats to the HIPAA-compliant standard formatReduction in time of claims preparationCost-effective method through loss preventionFewer claims rejectionsFewer delays in processing and quicker response timeMore accurate coding with claims editsConsistent reimbursementSome medical practices have direct links to the insurance companies and don’t use clearinghouses.CMS had created a standardized system for Medicare claims processing called the Medicare Transaction System (MTS).
8 Transaction and Code Set Regulations: Streamlining Electronic Data Interchange BenefitsMore reliable and timely processingImproved data accuracyEasier and more efficient information accessBetter tracking of transactionsReduction of data entry/manual laborReduction of office expensesHIPAA TCS was developed to make the healthcare system more efficient by achieving a single standard.Standard transactions are the electronic files in which medical data are compiled to produce a format for use in the health care industry.All healthcare organizations using electronic transactions accept the code set systems required by HIPAA.What is a “code set”? (The allowable set of codes that anyone could use to enter into a specific field on a form)See Table 8-1 (p. 268) for more on the benefits of TCS and EDI.
9 Transaction and Code Set Standards HIPAA required code and data setsICD-10-CM/ICD-10-PCS codesHCPCS codesCDT codesNDC codesTaxonomy codesPatient account numberRelationship to patientFacility code valuePatient signature source codeThe listed code sets and data are HIPAA-approved and should be used for all submitted insurance claims.What does “situational” mean? (That the items depends on the data content or context [See Example 8-1].)
10 Electronic Standard HIPAA 837P Electronic formatsSpecialist authorizationReimbursement claimsRequest and respond to additional informationHealthcare claims/attachments/claims statusCoordination of benefitsHealthcare payment and remittance advicePlan enrollment/disenrollment/eligibilityPremium paymentsReferralsFirst report of injuryOther transactions DHHS may prescribe by regulationProviders now must use the ASC X12 Version This version allows providers’ payers to transmit either ICD-9 or ICD-10 data.See Table 8-5 for a comparison of CMS-1500 and 837P v5010.
11 Claims Attachment Standards Supplemental documents providing additional medical informationCertificate of Medical Necessity (CMNs)Discharge summariesOperative reportsCurrently, PMS uses data field to indicate paper attachmentElectronic standards are going to be adoptedRegulation to be published in January 2014Compliance by January 2016A proposed rule was published in 2005, but the final rule was never adopted.
12 Standard Unique Identifiers Standard unique employer identifierStandard unique healthcare provider identifierStandard unique health plan identifierStandard unique patient identifierThe employer identification number (EIN) is assigned by the Internal Revenue Service (IRS), and is used to identify employers for tax purposes.HIPAA requires that a National Provider Identifier (NPI) be assigned to each provider for use in transactions with health plans. This is the standard unique healthcare provider identifier.Explain why the idea of a standard unique patient identifier is seen as a threat to civil liberties. (Answers will vary.)
13 Practice Management System Should be able to prepare, send, receive, and process HIPAA standard electronic transactionsCan help track receipt of Notice of Privacy Practices (NPP), patient treatment consents or authorization, and mapping disclosuresAn important function of a PMS is accounts receivable.A clearinghouse will convert older PMS formats to HIPAA standard transactions.Discuss how a good PMS can affect the medical office. (A PMS would improve office efficiency, reduce errors, and optimize reimbursement for services. Answers may vary from students.)Some PMS vendors sell add-ons that link directly to carriers such as Medicare, Medicaid, and Blue Cross Blue Shield.
14 Practice Management System Set security access to patient files in the softwareIndicate date of receipt and signing of NPPInsert date of patient’s authorizationMaintain files of practice’s authorization and notification formsTrack requests for amendments, restrictions on disclosure of PHI, and physician response to requestTrack expiration datesRemember that HIPAA standards apply only to the format in which data is transmitted. Data can be stored in any format within the PMS databases.
15 Encounter or Multipurpose Billing Forms Also called charge slip, multipurpose billing form, patient service slip, routing form, superbill, transaction slipCustomized to meet the needs of the healthcare officeMay include preprinted procedural or diagnostic codesScannable encounter forms save timeDoctors use crib sheets or summary forms with key information to ease the burden on them and allow them to focus on clinical matters instead of administrative matters.Some encounter forms are designed so that they may be scanned.An example of a scannable encounter form is in Fig Describe how a hypothetical patient’s primary and secondary diagnoses would be recorded on this form.
16 Keying Insurance Data for Claim Transmission DO: Use the patient account numbers to differentiate between patients with similar namesDO: Use correct numeric locations of service codes, current, valid CPT or HCPCS procedures codesDO: Print an insurance billing worksheet or perform a front-end edit to look for and correct all errors before the claim is transmitted to the third-party payerDO: Request electronic-error reports from the third-party payer to make corrections to the systemDO: Obtain and cross-check the electronic status report against all claims transmittedThe use of macros saves time and key strokes when completing electronic claims.
17 Keying Insurance Data for Claim Transmission DON’T: Use special charactersDON’T: Bill codes using modifiers -21 or -22 electronically unless the carrier receives documents to justify more paymentAlways do an edit check before submitting a claim, because the codes must match the documentation.
18 Encoder Signature requirements Physician Patient An encoder is a PMS add-on software that can greatly reduce the time required to build or review a claim before batching.A signed carrier agreement must be in place for each insurer accepting your electronic claim submissions (ECSs).Other signature requirements are needed for the physician and patient.
19 Clean Electronic Claims Submission Claim scrubber softwareEncoder softwareElectronic clearinghouseSingle and batch claims review“Dirty” claims can increase costs in the medical office. These methods increase the likelihood of clean electronic claims.Encoders and other software require an initial investment, but result in increased efficiency in the claims process.
20 Privacy and Electronic Data Lesson 8.2Privacy and Electronic DataName some methods of interactive computer transactions for transmitting insurance claims.Relate the electronic funds transfer process and mandated requirements under the Affordable Care Act (ACA).Identify the ASC X12 Health Care Claim Payment/Advice (835).List the procedures for transmission of an electronic claim.Explain the difference between carrier-direct and clearinghouse electronically transmitted insurance claims.
21 Privacy and Electronic Data (Cont’d) Lesson 8.2Privacy and Electronic Data (Cont’d)List computer transmission problems that can occur.List HIPAA administrative safeguards for electronic protected health information.State technical and physical safeguards used to secure privacy of , Internet, and instant messaging.Explain handling of data storage and data disposal for good electronic records management.Describe elements that should be considered when purchasing an in-office computer system.
22 Interactive Transactions Back-and-forth communication between two computer systemsReal time communication allows instant information transferName several transactions that can be done in real time. (Eligibility verification, deductible status, claim inquiries, status of claims. Answers will vary.)
23 Electronic Funds Transfer Electronic funds transfer (EFT) can speed up reimbursementFederal government has established a uniform procedurePart of HIPAA Administrative SimplificationHealth care providers must comply by January 2014The DHHS expects the elimination of paper checks to save physician and hospitals between $3 billion and $4.5 billion over the next decade by saving paper, printing, and postage costs as well as savings in staff time to manually process and deposit paper checks.
24 Electronic Remittance Advice Online transaction about the status of a claimMedicare ERAFormerly called Medicare explanation of benefits (EOMB or EOB)Based on American National Standards Institute (ANSI) Accredited Standards Committee X12 (ASC X12) Health Care Claim Payment/Advice (835) or ANSI 835The use of ANSI 835 Version 4010 generates an electronic Medicare remittance advice instead of the paper RA.ANSI 835 allows the electronic funds transfer (EFT) of Medicare payments to the physician’s bank account via direct deposit. This improves cash flow in the medical office.An example of a computer-generated Medicare RA is found in Fig. 8-8.
25 Driving the Data Set up the database Enter data Batch or compile a group of claimsConnect the computerized database with the clearinghouse or direct to the payerTransmit the claimsReview the clearinghouse reportsThese are basic procedures.More detailed steps may be required for different payers or to ensure secure data transmission.
26 Methods for Sending Claims Cable modemDigital subscriber line (DSL)T-1Direct data entry (DDE)Application service provider (ASP)Another dimension of a computer system is the network it is connected to, which is important in EDI.The medical office may use various methods, including data transmission (cable modem, DSL, T-1), DDE using dial-up or Internet, and ASP, or “renting” a PMS over the Internet.The ASP server houses the data, and accounts are managed by the health care provider’s staff. Claims are batched as though the software was on the desktop at the provider’s office.
27 Computer Claims Systems Carrier-directThe medical practice has its own computer and software to process claimsThe insurer sometimes leases a dedicated terminal to the physicianClearinghouseThe physician’s office sends paper claims or a disk or tape to the clearinghouse, which forwards a batch of claims to the insurerFiscal agents for Medicare and Medicaid and also many private insurers use the carrier-direct system.A clearinghouse is used if the physician’s system cannot be linked with the insurance carrier or if the insurer won’t accept claims directly from the physician’s office.
28 Transmission Reports Send and receive file reports Batch claim report billed summaryScrubber reportTransaction transmission summaryRejection analysis reportElectronic inquiry or claims status reviewTransmission reports are generated for both carrier-direct and clearinghouse claims.A status report of claims is sent from the insurance company to indicate electronic processing problems.
29 Electronic Processing Problems Upgrade to ASC X12 Version 5010 results in these common errors:Billing provider addressZip codeAnesthesia minutesPrimary identification code qualifiersBilling provider NPI numberNational Drug Code (NDC)Data transmission problems arise periodically because of hardware or software problems.If one claim in a batch contains an error, the third-party payer may reject the entire batch.See the textbook for some solutions to electronic processing problems.
30 Administrative Simplification Enforcement Tool Online toolAssists healthcare providers, payers, clearinghouses, and others to submit complaints regarding the HIPAA TCS ruleASET was implemented by the federal government.ASET addresses issues of noncompliance in regard to the transaction code set (TCS) rule.Discuss possible reasons for the use of ASET.
31 The Security Rule: Administrative, Physical, and Technical Safeguards Administrative safeguardsInformation access controlsInternal auditsRisk analysis and managementTermination proceduresWhen employees are terminated, their access to PHI should be removed. This means that passwords and security pass codes should be changed, and former employees’ accounts should be removed.
32 The Security Rule: Administrative, Physical, and Technical Safeguards Access controlsAudit controlsAutomatic log-offsUse of passwordsPhysical safeguardsMedia and equipment controlsPhysical access controlsSecure workstationAudit controls keep track of log-ins to the computer system, administrative activity, and data changes.Automatic log-offs can prevent unauthorized users from accessing an unattended computer.User names and passwords restrict access and identify computer users.Office policies and procedures (P&P) should dictate the destruction of obsolete data disks and software containing PHI, as well as the recycling of computers.Pass codes may be used to restrict access to administrative offices where patient files and data are kept.Ask students to consider a physician's office they have visited. Are they aware of the presence of physical safeguards?
33 Records Management Data storage: back up data frequently Data disposal: data must be complete eliminatedElectronic power protection: surge suppressors or uninterruptible power supply (UPS)Automated, computer-initiated data backup is available in most programs.A verification process should be done once a week, to compare original records with copies.Backup copies of data should be stored away from the office to protect against fire, flood, or theft.An all-office or whole-office surge suppressor can be installed near a circuit breaker panel to protect all office systems from damage.
34 Selection of an Office Computer System Cost of basic equipment—purchase or lease?AccessoriesSpace requirementsElectrical/transmission linesSeparate fax and modem lines?Costs of electricityTelephone linesMaintenanceSoftwareThis slide lists several points to consider when shopping for computers for the office.Most considerations relate to the costs.Describe some other costs and considerations to take into account when planning to buy a computer system.