Integrating Your EHR with EZClaim

Integrating Your EHR with EZClaim

Are you or your staff having to enter every patient into your EHR program and then again into EZClaim?  There is an easier way!  Integrating your programs will put an end to duplicate data entry, saving your practice time and money!

So, what exactly is an interface and how does it work?  An interface is a way for two programs to share information.  For EZClaim clients, the interface can be set up to share data from your EHR program to EZClaim.  Your EHR can give you specifics on how to send the data to EZClaim.

In EZClaim you will have an opportunity to review the file prior to saving the data.  When you complete the import process, your claims will be created, and libraries will be updated.  In addition to creating your claims for each visit, an interface can also create Physician/Facility library entries, as well as Payer library entries, and create new or update existing patient accounts.

If you are working with one of our partner EHRs (Visit our Partner List) the integration between programs can be set up quickly and easily.  Since the process varies slightly depending on the EHR you are using, time to complete the integration request will vary.

If you are not using a partner EHR, you may still be able to integrate with EZClaim.

Following are some options:

  • In our Online Help File the format types and specifications are available for you to share with your EHR vendor.  If they can provide a file in one of the required formats you will be able to import your data.
  • You may consider using a third party to write a custom interface for you.  If you would like more information on this, contact EZClaim and we will be happy to provide information on consultants who are familiar with the EZClaim platform.

If you have questions, please submit them via email to support@ezclaim.com so a technician can review them and get back with you.

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]

Defeat Medical Claim Denials With Data

Defeat Medical Claim Denials With Data

For many providers, medical claim denials are one of the single biggest drains on revenue. When you consider that working just one denial costs about $25, knowing why claims are being denied and how to prevent them in the future isn’t a luxury—it’s a necessity.

Automation and advanced analytics can take much of the burden off your billing team by helping you identify potential denial triggers, adapt to constantly changing payer guidelines, and uncover actionable trends in your claim data.

Waystar’s Denials by the Numbers:

  • 5-10% average denial rate amount physician practices
  • 90% of denials are preventable
  • 76% of providers say denials are their biggest RCM challenge

[ Note: View or download Waystar’s “Defeat Denials with Data” white paper here ]

Waystar, a partner of EZClaim, integrates easily with its medical billing software, creating a seamless exchange of claim, remit, and eligibility information. To learn more about defeating medical claim denials, or to add Waystar as your clearinghouse, visit this page.


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.

[ Article and white paper contributed by Waystar ]

5 Medical Coding Challenges That Hurt Revenues

5 Medical Coding Challenges That Hurt Revenues

In the world of healthcare revenue cycle management, there are numerous scenarios that can put a stranglehold on your revenue if you’re not prepared. With the COVID-19 pandemic causing varying degrees of change in inpatient volumes and visits, and telemedicine coming further into play, physicians and their practices are having to quickly navigate the nuances of their financial well-being. A practice may be buttoned up from the time the patient walks in the door, but what happens after the visit will determine when the practice will get paid. This element of the revenue cycle starts with coding. Here are five medical coding challenges that will ruin your bottom line.

1. Coding to the Highest Specificity
Missing data on a claim relative to the patient’s diagnosis and procedure can easily cause a rise in denials once received by the payers, resulting in potentially thousands of dollars in write-offs. Medical coders are responsible for coding patients’ claims to the highest level of specificity, ensuring the appropriate CPT, ICD-10-CM, and HCPCS codes are applied based on the patient’s chart from the day’s services.

COVID-19 and telemedicine are frequently bringing on new codes and code sets, all with different variations and modifiers to make the matter even more complex. Medical coders spend a lot of time researching and learning new codes, but every year – and throughout the year – changes and updates are made. Payers don’t only want to know the diagnosis and the treatment; they want to know the cause as well. The Coronavirus Aid, Relief, and Economic Security Act passed in March of 2020 allows for an additional payment from Medicare of 20 percent for claim billed for inpatient COVID-19 patients, however, it was later indicated that a positive COVID-19 test must be stored in the patient’s medical records in order to be eligible for this payment. Being able to stay on top of codes specific to the patient’s diagnosis at treatment is more difficult than ever before.

2. Upcoding
While code specificity is important, so too is ensuring the claims do not contain codes for exaggerated procedures, or even procedures that were never performed, resulting in reimbursement for these false procedures. This seems logical enough, but upcoding can easily occur as a result of human error, misinterpretation of a physician’s notes, or lack of understanding of how to appropriately assign the thousands of ICD-10-CM codes in existence. To add to the pressure, the Office of the Inspector General issued a plan with objectives to prevent fraud and scams, and remedy misspending of COVID-19 response and recovery funds.

Much like under-coding or not providing enough data on the patient’s visit can create issues, upcoding can be a major contributor to financial loss for a practice. Questionable claims can be denied and sent back for corrections and appeals, but upcoding can have more serious ramifications outside of paper-pushing between coders and payers.

Whether it’s making sure the codes are in accordance with the care provided, understanding the code sets that apply for each procedure, or comprehension of the medical record, refraining from upcoding will help ensure a sturdy and compliant revenue stream.

3. Missing or Incorrect Information
There’s a common theme to coding challenges, and that’s having the sufficient information necessary. This information typically is pulled from a patient’s chart or record of a visit, which is often completed by the attending physician. However, even when a claim is submitted, providing required information relative to the procedure to the payer is critical as well. Situations such as failure to report time-based treatments (such as anesthesia, pain management, or hydration treatments) or reporting a code without proper documentation can result in denials.

Furthermore, information in a patient’s electronic health record may also contain inaccurate information. Keystrokes and other human errors can cause these situations to flare up, and it takes a diligent, thoughtful coder to read between the lines and ensure claims have the appropriate information.

4. Timeliness of Coding
The Medical Group Management Association (MGMA) suggested in their 2018 Setting Practice Standards report that a Primary Care Physician should maintain a claim submission rate of 3.11 days after the date of service, but it is becoming increasingly difficult for practices to sustain anything close to this rate. Constant changes to code sets, an increased focus on submitting claims with sufficient and compliant information, and the requirement to code claims to the highest level of specificity, can easily delay the submission by days or weeks.

Nevertheless, delays in coding and submitting claims can cause major lags in payment and substantial loss in revenue. Insurance payers have statutes of limitations that require claims to be submitted anywhere from 120 to just 60 days after the date of service. Simply put – the more time spent coding the claim, the later it will be submitted, thus increasing the odds that the claim will be denied. Expert coders are aware of this and do everything in their power to get coded claims out the door.

5. Staffing Shortages
However, finding experts well versed in coding claims quickly, accurately and in compliance with the False Claims Act is not always an easy task. As you can imagine, the increasing need for care within the senior population is causing a rise in claim volumes, and trying to find a team of coders who know the ins and outs of complex ICD-10-CM coding can easily cause a bottleneck in the revenue cycle. Health executives expressed their struggles to find talent back in 2015, and some forecasts expect a decline in commercial payments by 2024 to further hamper a C-suite’s ability to manage labor costs. The ramifications of incorrect coding are still a key topic of discussion to this day.

The time has come for practices to begin looking outside of their organization for coding support. How is your practice planning to tackle the coding conundrum? When choosing a partner for your medical coding needs, you need to pick an expert to help your practice stay on target. TriZetto Provider Solutions, a Cognizant Company, has available highly-trained, AAPC & AHIMA certified coders with the experience of getting the details right the first time and understand the importance of coding to the medical practice.

For more information about TriZetto Provider Solutions, a partner of EZClaim, visit their website, contact them, or give them a call at 800.969.3666.


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 of the TriZetto Provider Solutions Editorial Team ]

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 ]