___.Claim that is submitted via telephone line or computer modemCleanclaim___.Claim that is submitted within the time limit and correctly completedInvalidclaim___.Medicare claim that contains information that is complete and necessary but is illogicalor incorrect
Getting paid promptly and accurately is a chief concern for many practitioners. Electronic claim submission is one tool practitioners are increasingly using to facilitate the claim reimbursement process. Practitioners are finding that transmitting insurance claims electronically to carriers managed care companies, and other health care payers can increase their practice's cash flow and help to streamline their billing operations. The trend toward greater use of electronic claims has also been prompted by the expectation that a growing number of insurers will require electronic claim submission in an effort to cut costs. Medicare payment policies have also encouraged the trend by requiring hospitals and clinics to submit all Medicare claims electronically. The shift toward electronic claims has also been prompted by the Health Insurance Portability and Accountability Act (HIPAA). In an effort to facilitate electronic exchange of health care payment information, the HIPAA Transaction Rule mandated the use of standardized formats for electronic claim transmission. Additional information about the impact of the HIPAA Transaction, Privacy and Security Rules is available in the "HIPAA compliance" section of APApractice.org. This article outlines the basics of electronic claim submission in order to help practicing psychologists learn more about — and make the transition to — this increasingly popular reimbursement option.
Filing claims electronically can offer a number of benefits, including:
Many different options and providers exist for submitting claims electronically. Following are some of the basic features of full-service and self-service electronic claims: "Full-service" Electronic ClaimsFull-service electronic claims are filed on behalf of a psychologist by a third party-often a billing service. The psychologist is required only to send basic patient and service information to the billing service, which then develops and submits the claim directly to the appropriate insurer or to a health care claims clearinghouse. How much does it cost? The billing service often retains a percentage of the total claim amount as payment for its services. The percentage retained often depends on the types of services provided, and can range anywhere from 4 to 15 percent of the total claim amount. "Self-service" Electronic ClaimsSelf-service electronic claims are developed and submitted by a psychologist (or a member of the psychologist's staff) directly to a third-party payer or health care claims clearinghouse. Practitioners who submit claims to only one or two payers may opt to submit their claims directly to the individual third-party payer using proprietary software provided by the payer. However, practitioners who submit claims to many different third-party payers often find it most convenient to submit claims to a single clearinghouse, where the claims are sorted, formatted, checked for accuracy and transmitted to the appropriate payer. Options for submitting claims to a clearinghouse include:
Additional self-service claim submission options may be available for an additional cost, enabling practitioners to perform such functions as:
The self-service option is often more economical than using a full-service billing service for solo practitioners and small practices, and provides the psychologist with an additional level of control over the sensitive personal information contained in a claim. How much does it cost to submit self-service electronic claims? Pricing may be determined on a "per claim" basis, a flat fee or a combination of a regular flat fee plus per-claim fees. Pricing may also be different depending on whether claims are entered via direct data entry or a file is uploaded from practice management software.
Many electronic claim providers exist in the marketplace, and practitioners should choose a provider carefully based on their administrative needs and budget. It is a good idea to talk to colleagues about services they use and recommend and find out if your practice management software includes an electronic claim submission component.
A patient received services on April 5, totaling $1,000. He paid a $90 coinsurance at the time services were rendered. (The payer required the patient to pay a 20 percent coinsurance of the reasonable charge at the time services were provided.) The physician accepted assignment, and the insurance company established the reasonable charge as $450. On July 1, the provider received $360 from the insurance company. On August 1, the patient received a check from the insurance company in the amount of $450. The overpayment was_____, and the_____must reimburse the insurance company. (Remember! Coinsurance is the percentage of costs a patient shares with the health plan.)
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