3 Learning Objectives (cont d.)

Transcription

1 1 2 Learning Objectives Summarize advantages of electronic claim submission. Identify the transactions and code sets to use for insurance claims transmission. State which insurance claim data elements are required or situational ional for the 837P standard transaction format. Describe necessary components when adopting a practice management t system. Describe the use of patient encounter forms and scannable encounter forms in electronic claim submission. Name some methods of interactive computer transactions for transmitting insurance claims. 3 Learning Objectives (cont d.) 4 List computer transmission problems that can occur. Explain the difference between carrier-direct and clearinghouse electronically transmitted insurance claims. State measures used to secure privacy of electronic mail, Internet, et, and instant messaging. List HIPAA administrative safeguards for electronic protected health information. Explain the handling of data storage and data disposal for good electronic records management. 5 Electronic Data Interchange (EDI) Used for transmission of health insurance claims Transmitted data is encrypted Improves efficiency of claims submissions 6 Advantages of Electronic Claim Submission No signatures or stamps No searching for an insurance carrier s s address No postage costs or trips to post office No need to store or file claim forms Electronic claims leave an audit trail Improved cash flow Quicker processing time and payment Reduced overhead and labor costs 7 Clearinghouses Claims are checked electronically Claims with missing/incorrect information are rejected Rejected claims are sent back to the provider with a report Batches of acceptable claims are sent to the appropriate payer Corrected claims are reprocessed 8 Advantages of a Clearinghouse Translation of various formats to the HIPAA-compliant standard format Reduction in time of claims preparation Cost-effective method through loss prevention Fewer claims rejections

2 Fewer delays in processing and quicker response time More accurate coding with claims edits Consistent reimbursement 9 HIPAA Transaction and Code Set (TCS) Benefits More reliable and timely processing Improved data accuracy Easier and more efficient information access Better tracking of transactions Reduction of data entry/manual labor Reduction of office expenses 10 HIPAA Required Code and Data Sets ICD-9-CM CM codes CPT-4 4 codes CDT codes NDC codes ICD CM/ICD-10-PCS codes Taxonomy codes Patient account number Relationship to patient Facility code value Patient signature source code 11 Electronic Formats Specialist authorization Reimbursement claims Request and respond to additional information Healthcare claims/attachments/claims status Coordination of benefits Healthcare payment and remittance advice Plan enrollment/disenrollment disenrollment/eligibility Premium payments Referrals First report of injury 12 Standard Unique Identifiers Standard unique employer identifier Standard unique healthcare provider identifier Standard unique health plan identifier Standard unique patient identifier 13 Practice Management System Should be able to prepare, send, receive, and process HIPAA standard electronic transactions Can help track receipt of Notice of Privacy Practices (NPP), patient treatment consents or authorization, and mapping disclosures 14 HIPAA-Ready PMS Set security access to patient files in the software

3 Indicate date of receipt and signing of NPP Insert date of patient s s authorization Maintain files of practice s s authorization and notification forms Track requests for amendments, restrictions on disclosure of PHI,, and physician response to request Track expiration dates 15 Encounter or Multipurpose Billing Forms Also called charge slip, multipurpose billing form, patient service slip, routing form, superbill, transaction slip Customized to meet the needs of the healthcare office May include preprinted procedural or diagnostic codes Scannable encounter forms save time Do s s and Dont s for Keying Insurance Data for Claims Submission 16 Do DO: Use the patient account numbers to differentiate between patients with similar names. DO: Use correct numeric locations of service codes, current, valid CPT or HCPCS procedures codes. DO: Print an insurance billing worksheet or perform a front-end edit to look for and correct all errors before the claim is transmitted to the third-party payer. DO: Request electronic-error error reports from the third-party payer to make corrections to the system. DO: Obtain and cross-check check the electronic status report against all claims transmitted. DON T: Use special characters. DON T: Bill codes using modifiers -21 or -22 electronically unless the carrier receives documents to justify more payment. 17 Encoder Signature requirements Physician Patient 18 Clean Electronic Claims Submission Claim scrubber software Encoder software Electronic clearinghouse Single and batch claims review Interactive Transactions Back-and and-forth communication between two computer systems Real time communication allows instant information transfer Electronic funds transfer (EFT) can speed up reimbursement 21 Electronic Remittance Advice (ERA) ERA: Online transaction about the status of a claim Medicare ERA formerly called Medicare explanation of benefits (EOMB or EOB) based on American National Standards Institute (ANSI) Accredited Standards Committee X12 (ASC X12) Health Care Claim Payment/Advice (835) or ANSI Procedures for Claim Transmission Set up the database. Enter data. Batch or compile a group of claims.

4 Connect the computerized database with the clearinghouse or direct to the payer. Transmit the claims. Review the clearinghouse reports. 23 Methods for Sending Claims Cable modem Digital subscriber line (DSL) T-1 Direct data entry (DDE) Application service provider (ASP) 24 Computer Claims Systems Carrier-direct The medical practice has its own computer and software to process s claims. The insurer sometimes leases a dedicated terminal to the physician. Clearinghouse The physician s s office sends paper claims or a disk or tape to the clearinghouse, which forwards a batch of claims to the insurer. 25 Transmission Reports Send and receive file reports Scrubber report Transaction transmission summary Rejection analysis report Electronic inquiry or claims status review 26 Administrative Simplification Enforcement Tool (ASET) Online tool Assists healthcare providers, payers, clearinghouses, and others to submit complaints regarding the HIPAA TCS rule 27 The Security Rule: Administrative, Physical, and Technical Safeguards Administrative safeguards information access controls internal audits risk analysis and management termination procedures Technical safeguards access controls audit controls automatic log-offs offs use of passwords 28 The Security Rule (cont d.) Physical safeguards media and equipment controls physical access controls secure workstation 29 Computer Security Prevention Measures Use software that stores files in coded form

5 Never leave disks or tapes unguarded Use a privacy filter on the computer monitor Log off computer before leaving work station Double-check credentials of all consultants Read equipment manuals, especially Security Controls information, and follow all directions Store confidential data on diskettes or zip disks, not the hard drive Store all diskettes in a locked, secure location Use firewall and antivirus software Develop passwords for all computer users Use only account numbers in e 30 Records Management Data storage: back up data frequently Electronic power protection: surge suppressors or uninterruptible e power supply (UPS) 31 Selection of an Office Computer System Cost of basic equipment purchase purchase or lease? Accessories Space requirements Electrical/transmission lines Separate fax and modem lines? Costs of electricity Telephone lines Maintenance Software