by BC Advantage
September 11th, 2018
We need timely and accurate patient information to bill health plans and receive appropriate payment. Clinical information is, of course, important. But we also need the "administrative" data - patient demographics and especially the insurance information. Physician offices create their clinical
Just as we have standardized electronic claims transactions and remittance advice transactions under HIPAA, there are standardized electronic eligibility inquiry and response transactions which can (and should) be used by physician offices to communicate with health plans. HIPAA regulation
These rules require that all health plans (including Medicare and Medicaid) must provide real-time (i.e. almost instantaneous) responses to eligibility information. The rules also expanded the information which must be provided in all responses. Health plans must now include, in addition to the membership status and beginning and end dates:
- Whether or not the patient is eligible for a large number of specific service types such as surgical, DME, hospital inpatient, hospital outpatient, dialysis, etc. as well as if the coverage in
- Patient financial responsibility for
baseand remaining deductible, co-insurance and co-payment for each service type requested.
Providers can now request and receive all of this information from health plans on a
First, make sure that your practice management system or clearinghouse gives you the capability to do these
If your vendor doesn't support the transaction, find out if you can get it added to your system. If not, you may wish to investigate alternatives.
If you do have the capability, it's time to put it to good use. The health plan eligibility status and financial standing for each patient should be available to front office staff before the patient walks in the door. I would recommend that near the end of the day, eligibility inquiries
Every health plan is required to have this detailed, real-time eligibility inquiry and response process. This is based on the standard transaction required under HIPAA. While health plans may, at their option, also offer Web portals with this information, they cannot force you or provide
Remember - claims are easily denied if the insurance information is incorrect. And with the rapid changes in the
This Week's Audit Tip Written By:
Principal, Nachimson Advisors LLC
Stanley Nachimson is principal of Nachimson Advisors, a health IT consulting firm dedicated to finding innovative uses for health information technology and encouraging its adoption.