, a leading electronic data interchange (EDI) clearinghouse helping to streamline the billing and collection process for providers, payers and software vendors

Rob Stuart

Although medical practices that focus solely on workers’ compensation claims do exist, even more medical providers accept workers’ comp cases along with regular patient appointments.

Accepting different types of insurance such as workers’ comp can help practices gain top-line revenue — as long as billers submit claims data in a way the insurer will readily accept. Studies vary, but some medical practices have clean claims ratios as low as 65%, which means 35% of claims need to be reworked, efforts that delay payment by days or weeks and cause additional work for already overburdened back-office staff. Those delays cost practices an estimated $20 billion a year in 

Workers’ compensation cases can be particularly troublesome because insurers require documentation of the work-related illness or injury and progress toward recovery, increasing the onus on practices. State regulations about claims filing differ, but electronic claims are generally accepted and paid more quickly than paper ones. However, unwieldy methods of attaching files or reworking claims create problems for medical practice staff who often resort to snail mail or fax machines, delaying reimbursement further.

Filing workers’ comp claims shouldn’t be a pain in the neck, which is why medical staff need solutions that make the workers’ compensation claims process as easy as possible.

Electronic much better than paper for quick payment

When it comes to filing workers’ compensation claims, electronic is definitely the way to go for providers who want to be reimbursed for their time and effort as soon as possible. However, state regulations vary widely on how these claims should be filed and how soon they will be paid. These differences can create significant barriers to prompt claims payment.

Workers’ compensation carriers in California, for example, are required to pay a 

 within 15 days of receipt, compared with paper claims that give payers 45 days of leeway between receipt and payment. Orthopedic practices cited in a report say they are receiving reimbursement for electronic claims within 10 days and with fewer claim rejections.

For medical office billers, workers’ comp claims vary significantly from those required for private insurance or federal payers like Medicare or Medicaid, which can lead to difficulties producing clean claims and receiving timely reimbursement. Workers’ comp carriers require extensive documentation to accurately describe the on-the-job illness or injury, detail a treatment plan, and show how subsequent visits and/or treatments are progressing the patient back to health/mobility as outlined in the treatment plan.

Lack of adequate documentation delays payment and creates a significant burden on practices. There has to be a better way.

Many claims management systems are difficult to use

Providers need a claims management software system that readily accommodates attachments, a feature that remains aspirational for many software vendors. Sure, vendors may offer a hard-to-navigate portal or some odd upload option that doesn’t work half the time. What billers want is an attachment system that’s as easy as creating a PDF, clicking the “attach” button, and pressing “send” to transmit the claim and the proper documentation as a single document.

For billers facing difficulty with their claims management system, one common workaround is to send paper copies of the claim, which takes much more time and increases accounts receivable (A/R) days. Billers who file electronically might also wait for the inevitable rejection or request for more information, which often includes a barcode that must be included with the additional documentation to synch up the claim and the paperwork. When the objective is to receive the proper reimbursement in the least amount of time, neither of these methods will produce the desired results.

What to look for in claims management software

Like other types of software a medical practice uses, claims management software should work 

 users and not the other way around. As practice veterans know, however, the advent of new software often requires the practice to reconfigure workflows to accommodate how the software needs information to be presented.

Look for software that accommodates the types of claims the practice files most often. Can the same software handle private insurance, Medicare/Medicaid, and workers’ comp? If the practice is a rural health clinic, can the claims management system also easily handle those claims?

Practices also need claims management software that analyzes claims for potential denials on the front end. The software should present any claims that need a second look as a notification, much like smartphone users get calendar reminders for upcoming appointments while using their phones. Proactive notification lets billing staff reexamine flagged claims for anomalies and resubmit them immediately, rather than wait for a denial, a process that could take weeks. Denials consume staff time and resources to resubmit, and a large percentage of denied claims are never resubmitted for reimbursement.

Any claims management system should support the quick and easy attachment of notes and documentation that must accompany certain claims, such as workers’ compensation.

While patients likely consider physicians as their healthcare heroes, billing and claims staff are the heroes of the practice, working hard to ensure that office visits and procedures are billed correctly the first time to maximize revenue and speed reimbursements that are the lifeblood of every practice.

Utilizing a robust claims management system can help billing staff perform their tasks more efficiently and with a higher clean claims rate that can mean the difference between speedy payments and denials that slow the reimbursement process even further.

, a leading electronic data interchange (EDI) clearinghouse helping to streamline the billing and collection process for providers, payers and software vendors.

Articles

Workers’ compensation cases can be particularly troublesome because insurers require extensive documentation. 

Processing workers’ comp claims shouldn’t be a pain in the neck

How to streamline claims for rural practices

Slideshows

Follow these tips to turbocharge the claims process.



The Centers for Medicare & Medicaid Services (CMS) 

 in defined rural environments, paying encounter rates for provided services provided and the overhead required to provide them.

. Rural health clinic (RHC) leaders must keep track of the services provided and submit yearly totals. They also must submit and process 

differently for patients and services covered under the rural health initiative and those submitted as fee-for service engagements.

These differences can present challenges for 

, which may not have the level of billing and coding expertise that suburban and urban practices enjoy. When days in accounts receivable (A/R days) pass three weeks, physicians are more likely to need to dip into personal funds to make payroll, placing additional pressures on rural practices.

Understanding coding differences, submitting clean claims the first time, and editing claims as close as possible to rejection can go a long way toward returning rural practices to their core goal of taking the best possible care of patients.

Rural medical practices can improve the efficiency of their operations with the right claims software that helps them take these four steps:

Process claims in dual billing environments

Rural health clinics often operate in two conflicting worlds, with UB-04 claims for Medicare and 1500 claims for fee-for-service visits for patients who are not covered by the rural health initiative. The claim forms are very different, so your staff must be bilingual coders who understand both sets of claims.

Often, RHCs use different billing software or billing services for each claim type, which drives up costs and presents training challenges for staff. Any turnover among billing staff compounds the pain, likely reducing the pace of claims submissions that can slow vital reimbursements while new staff are hired and increasing the likelihood of incomplete and/or rejected claims.

RHCs should look for billing software that allows easy submission of both UB-04 and 1500 claims, reducing the level of effort required to submit claims and increasing staff efficiency.

Submit an electronic 1500 form for fee-for-service, and the insurer likely will tell you up front if there are glaring errors in the claim, such as a name mismatch. You will need to wait for more subtle rejections such as the wrong CPT code or invalid procedure for someone of a particular gender, but the insurer, at the least, takes a cursory pass at the claim.

Submit a UB-04 claim to Medicare and prepare to wait for 21 days for 

 type of determination. In this environment, any errors — glaring or otherwise — are compounded by the three-week window before a denial.

Rural health providers need claims software that allows for front-end edits before Medicare receives the claim. Claims software can’t suggest specific CPT codes for particular procedures, but savvy software providers can compare CPT and revenue codes, for example, and identify any mismatches. Software should also flag medically unlikely amounts of supplies or procedures and CPT codes that shouldn’t be billed together.

Much like Medicare waits 21 days to notify rural health clinics of denials, many clearinghouses follow a similar methodology, sending periodic reports that provide a snapshot of claims in that moment in time. Billing staff must pore over the reports to determine any anomalies and dive deeper into rejections. Days may pass between when a report is compiled and when billers have time to interact with the report — days that the practice isn’t getting paid.

Clinics need claims software that serves up denials as soon as they’re identified and as part of normal workflows. Quicker notification of claims that likely will be denied leaves billers more time to examine each anomalous claim and the proactive steps to submit a claim that will be reimbursed properly.

Just like denials, explanation of benefit (EOB) statements are often periodic, with RHCs receiving them in the mail or billing staff having to download them from the insurer. To understand how EOBs impact revenue, billers need to look at every form to ensure revenue is posted properly and determine whether patients owe additional money because a visit or procedure falls under their deductible.

Clinics need software that examines every EOB, matching claims and returning any anomalies (contractual adjustments and patient responsibility, for example) back to billing staff immediately. Billers, rather than examining every EOB, can look through the returned EOB list to determine why the claim wasn’t paid in full and what the next steps should be. By immediately returning claims that need further work, rural health clinics can shorten the time between patient visit and payment.

Often, rural health clinics hold communities together, providing critical services that keep people from traveling greater distances to access healthcare. But staffing can be a challenge, especially finding and training billers and coders who understand the intricacies and nuances of both UB-04 and 1500 claim forms. And lost time submitting, monitoring, and reconciling claims extends A/R days, which can leave RHCs strapped for cash.

Clinics should explore claims software that processes both UB-04 and 1500 claims, provides UB-04 editing capabilities, returns denial alerts as part of normal workflows, and reconciles every EOB to claims expectations.

Follow these tips to turbocharge the claims process.