Healthcare News & Insights

Best practices, benefits of electronic healthcare transactions for medical, workers’ comp and auto claims

Electronic medical billing and claims processing, now recognized as healthcare electronic data interchange (EDI), have brought greater efficiency to the nation’s healthcare industry. In this guest post, William DeGasperis, president of specialty services at a specialty risk transfer, care-coordination company, details how EDI significantly improves the accuracy of claims submission and streamlines administrative procedures that result in faster adjudication and payment, and how the workers’ comp and auto sectors are catching up with this move to abandon paper-based processing and adopt a streamlined, expedient approach.

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The ample benefits of electronic transactions include simplified paperless management, automatic processing to eliminate redundancy and quick dissemination of information. Furthermore, providers gain the ability to instantly check a patient’s insurance eligibility and link billing to existing accounting systems.

An electronic approach also lowers administrative costs for providers, since it requires less staff time and office overhead. What’s more, it’s a positive change that enables providers to focus increased time and attention to patient care. Providers also value the ability to more easily customize patient medical and personal data to include location, medical history, diagnosis and insurance policy information, along with other information.

Electronic filing of medical bills for auto claims is taking hold in many states. In New Jersey, for example, new legislation requiring this change was enacted: NJ State Bill S-2137 requires electronic submission of automobile insurance claims between healthcare providers and insurance companies or their third-party administrators (TPAs).

Under this newly enacted legislation, it’s mandatory that all automobile insurance carriers, TPAs and medical management companies that receive auto-related medical bills from healthcare providers accept and process the bills electronically. Moreover, it requires all healthcare providers and hospitals that submit over 25 auto-related medical bills per month to now provide electronic bills for payment on standardized forms compliant with guidelines.

Additionally, the N.J. Workers’ Compensation EDI Law (Senate P.L. 2016 C64) requiring employers, workers’ comp insurance carriers of employers or workers’ comp TPAs to accept electronic medical bills submitted for the payment of medical services was approved on May 21, 2018, and allows for an 18-month adoption period.

Best practices

Clearinghouses are electronic stations, or hubs, that allow healthcare providers to transmit electronic claims to insurance carriers in a secure way that protects patient health information. They offer medical billers and billing managers a way to consolidate all their electronic claims and manage them from a single location via online dashboards.

These different types of claims clearinghouses are varied, including claims for pharmacy, dental, durable medical equipment, in-patient and out-patient facilities, and medical professionals.

Clearinghouse responsibilities for workers’ comp or auto bills include:

  • validate for bill completion prior to transmission to payor
  • notify provider if data is missing or in error
  • transmit supporting documents/medical reports to payor with bill, and
  • pass payor acknowledgement of bill back to providers.

The most highly regarded clearinghouses provide credible revenue cycle management intelligence that makes their services extremely compelling in terms of cost and efficiency. The average error rate for paper claims is 28%, but using a top clearinghouse can reduce that to 2%.

When seeking a quality healthcare clearinghouse look for these features:

  • eligibility verification to determine patient portion before appointment
  • electronic remittance advice (ERA) to automatically update payments and adjustments
  • claim status reports
  • rejection analysis to help translate error codes
  • online access for editing and correcting claims online
  • real-time support for personnel, one-on-one support and training
  • claims that can be printed but also tracked and managed online, and
  • affordability when compared to the cost of purchasing forms, printing, envelopes, postage and time spent.

A clearinghouse helps healthcare professionals catch and fix claim errors in minutes rather than days or weeks. The result is fewer denied claims and significantly higher claim success, as well as fast claims processing, ability to file claims in batches and reduction in human error.

Using a clearinghouse helps to improve provider relationships with insurance carriers, mitigates long wait-times for claim enquiries and shorter payment cycles that lead to more accurate revenue forecasts.

Carrier perspective

Insurance carriers should review their current processes and determine what needs to be done to improve efficiency. The best eBill vendors provide identifiers to specifications to easily find the source and allow cross reference to the vendor system.

Carriers shouldn’t simply accept what they’re given but choose the eBill vendor that can deliver what they need by looking at their current system to determine opportunities in terms of automation of processes post receipt, building in benefits for the provider and finding ways to process bills faster.

The first step is to decide priorities:

  • at a minimum, a clean and complete bill
  • an image of the bill
  • ability to get claim number
  • give providers processing status, and
  • payment information delivered to the provider.

Most eBill vendors are effectively agents of both the provider and the payor. Therefore, it’s important to make sure the contract delineates the relationships, so the vendor only becomes the agent once the provider delivers a complete clean bill and associated attachments.

Checklist:

  • know what is wanted and required
  • make sure adjusters get what they need
  • look for ways to maximize the benefits
  • leverage the partner’s capabilities
  • ensure ease of cross-referencing, and
  • make it beneficial for the provider.

Finding the right partner

Leading nationwide claims clearinghouse platforms give providers technology-enabled solutions that can positively impact treatment outcomes for injured workers.

Look for a clearinghouse that:

  • specializes in the electronic processing of not only healthcare claims but also workers’ comp and automobile bills
  • offers advanced tech-enabled capabilities in this space, and
  • contracts with major medical management companies and covers automobile policies.

These features enable partners to quickly comply by seamlessly connecting to all medical billing systems. E-billing leads not only to faster payment, but also increased efficiency of direct point-to-point communication between the insurance carrier and the provider billing system. Ultimately, implementation of electronic filing of all medical claims leads to an overall reduction in administrative costs and a more efficient process.

William DeGasperis is president of specialty services at Concordia Care, a specialty risk transfer, care-coordination company servicing insurers, government entities, self-insured plan sponsors and other managed care organizations.

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