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Integrating an EHR and PM – RCM Insight

Integrating an EHR and PM – RCM Insight

Have you ever been a bit overwhelmed when shopping around for all your medical practice needs?  Of course!  There are so many pieces required to meet all the HIPAA and reporting requirements, but it’s also about efficiency and ease of sharing information between clinicians to administrators.  This can make the all-in-one Electronic Health Record (EHR) and Practice Management (PM) systems very tempting.  Keep in mind, you will pay a hefty price for an all-in-one, which makes this a very simple decision for some practices.  The good news:  You have alternatives that still provide the same ease of sharing data through integration.  I recently interviewed Dan Loch, President of EZClaim Software, LLC.  EZClaim offers a stand-alone billing platform that offers several options for integration with clearinghouses and EHR’s.  I asked Dan what he felt the biggest advantages were to using stand-along programs.

    1. Your practice will get the best of both worlds! Often practices will find a great EHR, but the billing side is not the best, or vice-versa.  Using stand-alone programs that can talk to each other allows a practice to choose an EHR solution that is best for their clinicians AND a PM solution that is best for the billers and administrators.
    2. Typically, stand-alone systems are more ‘nimble’ in responding to industry and regulatory changes.
    3. Integrating multiple ‘best-in-class’ software packages creates an offering with much more in-depth capability.

If you are currently using separate EHR and PM solutions but the programs are not integrated – consider looking into this feature.  This will relieve the burden of entering data twice.  Start by verifying if the programs have an existing integration.

    • If so, the hard part is done! Just ask what the process is to get set up and if there are any fees associated.
    • If not, consider contacting your PM software vendor to inquire what formats they accept for EHR integrations. Once they provide the specs, work with your EHR to determine if you can export in the required format.

There is no single solution that works for every practice.  If you’d like to learn more, check out this article from EZClaim ‘All-in-One’ or ‘Specialized’ Medical Billing Software?  Which is Best?  I hope that this information will help you weigh your options and find the right fit for your specific situation.  If you have questions or would like some help determining what would be best, RCM Insight is here to help!  Visit us at www.rcminsight.com and submit a request to chat on the Contact Us page.

 

Processes for Rejections & Denials – RCM Insight

Processes for Rejections & Denials – RCM Insight

Last month we looked at tools for getting clean claims out the door on the first try.  Many billers or practices stop monitoring claims once the leave the practice management program, but this is where you are likely losing money. The unfortunate truth is you need to use the tools available to you to catch rejected and denied claims to ensure proper and timely payment.  Today we will look at rejections and denials, and the resources you have (or need) to work efficiently.

The terms rejection and denial are used interchangeably in the billing world but they have distinct differences, including how you are notified.  Let’s start with defining the differences.

Rejected Claims

  • Claims can be rejected by the clearinghouse OR the payer
  • Rejections are based on submission guidelines
  • Rejected claims have not been entered into your payers system for adjudication
  • Notified through a claim status report (ANSI 277) that comes back into most practice management programs from the clearinghouse
  • Corrections do not require a resubmission code

Denied Claims

  • Claims are denied by your payer
  • Denials are based on policy coverage
  • Denials have been accepted for adjudication and deemed unpayable
  • Notified on remittance advice (ANSI 835/ERA)
  • Payers may require a resubmission code and original reference number when submitting a corrected claim

If you are using a clearinghouse and receiving your claim status reports electronically, you will be notified quickly about rejected claims.  There are two ‘checkpoints’ that will look for errors.  The first is your clearinghouse, the second is the payer.

At each checkpoint claims will be Rejected or Accepted, these status updates come to you through a claim status report.  If your practice management system is able to process these reports (ANSI 277) your claims will be updated with the accepted or rejected information you will be able to correct any rejected claims within your practice management system.  When you see an error, start with checking who has rejected your claim.  This will be the point of contact if you have questions about the rejection or how to correct it. If you are not already, make it a daily task to get your reports, correct any rejected claims, and resubmit those claims.

When a claim has been accepted by your clearinghouse and the payer it enters the adjudication system.  This is where the payer will make a determination on payment based on the members coverage and your contract.  The denials will appear on your remittance advice with a payment or as a zero dollar payment, indicating that they have reviewed your claim and they have determined no payment is applicable.  If you are enrolled with you payer for electronic remittance advice (ERA) this file will come electronically and your practice management system will be able to list or identify denied claims.  These claims will either need to be researched further for clarification on the denial or written off.  It is vital that your practice management system can handle these scenarios appropriately so you do not lose money for payable services.

This is another scenario where technology can seem scary.  However, efficiently monitoring and working is well worth the learning curve.  If you are already sending electronically and not using the claim status report or electronic remittance advice – coordinate with your clearinghouse and practice management system to find out how these reports can save you time and money.

If you would like more information on creating workflows for rejections, denials, or enrolling with a clearinghouse, let RCM Insight help! Visit us at www.rcminsight.com to request a consultation.

[Contribution by Stephanie Cremeans with RCM Insight]

Why Did My Medical Billing Claim Get Denied?

Why Did My Medical Billing Claim Get Denied?

If a medical billing program has “scrubbing,” why did my medical billing claim still get denied? It is a common question that we are going to answer today.

First, let’s get a better understanding of the words we are talking about.  In the medical billing world, validation and scrubbing tend to be used interchangeably.  While they are similar – they are not actually the same. Understanding what you have and what you need will help you submit ‘clean’ claims.

According to Technopedia, data validation checks for the integrity and validity of data and ensures the data complies with the requirements. So, what requirements? Often people assume that this means payer requirements, but that is typically not standard. Validation rules are built into your practice management software and can be used for several points.  Following are some common rules you may find in your program:

  • Ensure NPI‘s and Tax IDs are the appropriate lengths
  • Ensure patients date of birth is entered
  • Ensure that a procedure code and place of service are present on each claim

 

While these scenarios are standard across the industry, there may be other situations that a validation rule can help. Some programs will allow you to create custom rules for your practice. A customized validation rule will allow you to create a rule for a payer requirement.  For instance, you could create a rule to prevent the following:

  • Do you have a code that always requires a modifier, but only for a specific payer?
  • Work with pediatrics and always need the ‘relationship to insured’ to read something other than self
  • How about insurance ID numbers that are a specific alpha-numeric combo, like 3 letters followed by 9 digits?

 

Keep in mind, if you are creating validation rules the program will make sure that the criteria are met based on the rule entered into your software. When creating custom rules, it is important to note that this will not verify payer billing guidelines. You will need to obtain information directly from your payer to create a rule that coincides with their policies.

Once any validation errors have been addressed your claims will go to the clearinghouse you are working with. Most clearinghouses offer claim scrubbing for an additional fee.  Technopedia defines data scrubbing as the procedure of identifying and then modifying or removing incomplete, incorrect, inaccurately formatted, or repeated data.

 

Claim scrubbing is available in several ways. It may be used within your practice management system, your clearinghouse, or even a third-party vendor. Claim scrubbing services can vary greatly in what they are looking for.

Once the claim has left your practice management system it will likely go through at least 2 scrubbing programs—one with the clearinghouse and one with your payer, prior to accepting the claim for processing. When claims are found to have an error, these results are sent back through a Claim Status Report (ANSI 277 file or a human-readable text file). This report will include information about why the claim cannot be processed. This report will also indicate whether it is the clearinghouse or the payer that is rejecting the claim. If you have further questions about the rejection, you will need to contact the entity that has rejected it.

 

Checking the Claim Status Reports on a regular basis will help you correct the errors and resubmit in a timely manner. In addition, the information you have gathered from the rejections can be used to update internal processes or create customized validation rules to prevent future rejections for the same error–saving you time and money!

RCM Insight is a medical billing company that uses EZClaim’s medical billing software. For any details that have to do with claims validation and “scrubbing,” contact RCM Insight directly.


ABOUT EZCLAIM:
EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support. Combined, they help improve medical billing revenues. To learn more, visit EZClaim’s website, e-mail them, or call them today at 877.650.0904.

[ Contribution by Stephanie Cremean’s with RCM Insights ]