Medical groups can boost their bottom line and refine operational efficiency by streamlining claims adjudication. Electronic submission enables practices to process claims and receive reimbursements quicker than they otherwise would have in the past.
As a whole, industry-wide electronic claims submission to payers is sharply on the rise. Indeed, the percentage of claims received electronically was 94 percent in 2011, up from 82 percent in 2009, 75 percent in 2006 and 44 percent in 2002, according to America’s Health Insurance Plans (AHIP), a national trade association representing the health insurance industry.
The process can still lag, however, because of a number of variables. For example, in 2011, 66 percent of claims were received by health plans within two weeks of the patient service date, but 16 percent of electronic claims and 54 percent of paper claims were sent to payers from providers more than 30 days after that date. Nine percent of all claims in 2011 were received more than 60 days after the service.
Interestingly, nearly 80 percent of all claims were adjudicated automatically in 2011. The average cost of processing a claim was $1.36. The average cost of processing an automatically adjudicated claim was $0.99; the average cost of processing a “pended” or delayed claim (a claim that required additional information or more complex manual processing) was $3.99 per claim.
Clearly there’s financial incentive for making the process painless and automatic. Every efficiency helps, particularly where adjudication can easily slip to 60 days or more.
Keeping the process simple is important, and electronic attachments used to support adjudication may be a step in the right direction, especially if a claim is pended for further review by the payer. Obviously, the payer determines what will be paid on a medical claim, but the decision often involves requests for supporting documentation or even entire patient medical records from the provider. Digital attachments ease transmission of records and supporting documents.
Though attachments are only required in a portion of medical claims (about 10 percent), they have been shown to have a significant impact on the speed of reimbursements because soliciting and preparing paper attachments slows the process. Payers typically solicit attachments two to four weeks after the initial submission; therefore, practices adding digital attachments can shorten this cycle, in some cases reducing their outstanding receivables by 10 to 14 days.
Providing a complete set of records during the initial submission creates a greater chance that the payer will be able to proceed with adjudication on a simple first pass. Keep in mind that insurance reviewers only have so much time, which is limited by how much documentation they have to wade through. Any increase in efficiency likewise increases the number of claims they can process, and results in quicker turnarounds for providers and patients. Electronic attachments have been shown to result in fewer denials and re-work requests, particularly since the typical cause for these delays is a failure to provide required or requested documentation to the payer in a timely manner.
All sides want to see claims adjudicated as quickly as possible. Because of advancements of electronic attachment technology — even with Medicare’s expansion of its audit program allowing providers the ability to send supporting documentation electronically — solutions for practices now provide a simple way for practices to streamline, serve and save.
Source: Medical Practice Insider