February 2007, Volume 3, Issue 2
Published by AEGIS Communications
Using Technology to Increase Efficiency
Technology continues to enhance many aspects of today’s health care industry, and dental practices are no exception. Electronic transactions are becoming more common in dental practices than ever before, resulting in millions of submitted claims, insurance-eligibility verifications, and claim-status requests being electronically processed each year. Providers experience a variety of benefits offered by constantly evolving health care-technology solutions, especially those providing electronic claim submission and real-time transactions.
Electronic claim submission, one of the most widely adopted of these technologies, has enabled dental practices to conduct everyday business more efficiently, more accurately, and less expensively. By submitting a claim through an electronic data interchange method, the need for sending paper claims is becoming obsolete. Providers not currently submitting claims electronically may be surprised at the simplicity of the process.
Virtually all software companies that provide practice-management systems incorporate the capability of producing an electronic claim. Providers should contact their software vendor for additional information. If this function exists in their application, the provider can typically be guided by the software through the steps on how to create an electronic claim.
Once the ability to generate an electronic claim has been established, a communication link will need to be created between the provider and the receiver, which may be a health care clearinghouse or the practice-management system’s software vendor. If claims are to be received by the provider’s software vendor, they will be collected and submitted to a clearinghouse, which provides the actual links to the dental payers. This way, providers are able to reach hundreds of payers through a single electronic connection.
By processing claims electronically through a practice-management system, providers gain the benefit of using claim desktop-editing tools to minimize errors before submitting the claim and to reduce the possibility of rejections by the payer. An example of desktop-editing capabilities is the validation of the ADA code noted on the claim and the assurance that it corresponds with tooth surfaces. Edits can also check for the completion of all required claim fields before allowing a claim to be submitted. Once claims passed through the edits and corrections are made, they are forwarded to the clearinghouse directly from the provider or through the practice-management software vendor.
When received by the clearinghouse, claims are reviewed using payer-specific edits, further ensuring that clean claims are being submitted to the payer. Payer-specific edits can identify a number of potential claim issues; for example, claims that cannot be sent electronically because of the payer’s inability to receive electronic claims, or ensuring that payer-assigned identification numbers are included if required. If the payer cannot receive the claim electronically, the “clean” claim can be printed and mailed without requiring additional manual steps from the provider. By allowing a third party to perform these functions, providers eliminate the time-consuming tasks of printing and mailing the claims as well as the burden of maintaining correct payer information, mailing addresses, etc.
After the claims are submitted, providers receive various reports generated by their practice-management system and the clearinghouse, which allows for the internal tracking of submitted claims and alerts providers immediately of all payer rejections.
One important asset gained from submitting claims electronically is the possible decrease in the time it takes to receive funds from the payer. On average, most electronic claims are paid in 14 days or less, with some payers sending payments within 7 days. As electronic claim submission continues to grow, many payers are moving toward immediate adjudication or payment of electronic claims. Some payers now offer electronic fund transfer for faster posting of payment to the provider’s account.
Communications between the provider and the payer are essential for effective billing management and, by submitting claims electronically, providers are able to receive notification of rejections or requests for additional information from the payer generally within 1 business day of the submission.
The benefits of dealing with payers electronically are not limited to claim submission. Providers can also verify patient eligibility, check claim status, and track claims in real time through the established electronic connection.
Many payers are offering access to patient information directly through their Web sites. Clearinghouses offer similar services through their own Web portals, allowing providers to access a variety of payers through a single Web site. By accessing these sites, providers can interact directly with payers in real time to follow up on the status of submitted claims and to verify eligibility, all while the patient is in the office. Many practice-management vendors have integrated real-time services within their software, enabling the provider to access data even more easily.
Real-time claim status allows providers to stay informed of the status of their claims throughout the submission process. Claims can be searched using a variety of information, including service date or date range, patient name, payer, and adjudication status. Details of the claim can be viewed as well as status messages, which may include the date the claim was submitted and the date accepted by the payer. Payers may also provide the payment amount, the date and number of the check, and a line item breakdown of the payment.
Verifying eligibility in real time is vital for dental practices. During the registration process, providers can access eligibility data, providing not just confirmation of coverage, but also up-to-date detailed benefit information, such as plan maximums, deductibles, and percentages paid by category. In some cases, use and frequency information is returned, along with in-network and out-of-network details. Some payers even allow providers to request information by a specific procedure code. Most importantly, the eligibility information received is displayed in an understandable, easy-to-read format that can be printed and shared with the patient. The benefits of electronic, real-time transactions are truly evident when compared with the time that is required using other means for communicating with payers.
The estimated time spent by providers using electronic transactions vs manual transactions is significantly different, with electronic transactions requiring only seconds vs several minutes for manual transaction. The reduced time required to check eligibility, claim status, or perform other transactions directly results in money saved by freeing staff to perform other tasks. In addition to the decrease in time required to process a transaction, the availability of services is improved as well. Through electronic communication methods, such as clearinghouse Web portals, providers can access patient information 24 hours a day, 7 days a week.
INTO THE FUTURE
The business of dentistry is changing clinically and administratively, and while change can be intimidating, the benefits to be gained from converting dental office tasks from manual to electronic methods can result in improved patient care and a streamlined revenue cycle.
Some complications do still exist with the current system for sending electronic claims, mainly with issues surrounding claim documentation or attachments; however, options are available to assist in providing payers with the information they need to process these claims. Providers are encouraged to routinely review the payer’s Web site, where updates concerning attachment requirements and the payer’s ability to accept them electronically are regularly updated. Despite any minor issues that may exist, electronic claim submission continues to provide significant benefits over traditional manual submission methods.
Emdeon Business Services delivers comprehensive electronic solutions that increase efficiencies and profitability for dental practices. For more information on how Emdeon can help your practice with all electronic transactions, call 888-416-0673 or visit www.emdeondental.com.