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

Rob Stuart

How to streamline claims for rural practices

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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.

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Follow these tips to turbocharge the claims process.