How does a Medical Office gain insight into what their Medical Billing Service is doing with Medical Claims?

A medical office is outsourcing their claim billing to a medical billing service. The medical office has no transparency into what is happening with their medical claims and they were asking me what steps they should take to gain access to the billing services electronic medical claim clearinghouse Office Ally.

The Medical Office's concerns are the lack of insight into all electronic claims, which claims are getting submitted, are any kicking out, if they are getting claim denials what are the reasons, how often is the medical billing service actually billing their medical claims, and what percentage of claims are getting passed on to the health insurance carrier? Because of these concerns they want access to the electronic claims clearinghouse.

Let's first review how the medical claims clearinghouse Office Ally works?

1. All data is entered into the Practice Management/Billing Software



2. A claim file is generated



3. The claim file is downloaded to the desktop



4. The user logs into Office Ally
   
   
5. The user uploads the claim file from the desktop into Office Ally Clearinghouse Software
   
   
6. The user submits these claims electronically through Office Ally after it passes through certain claim edits
   
   
7. Any denied claims will be received in a report format, the medical billing service should be fixing the issues in both the claim clearinghouse software and in their Practice Management Software
   
   
8. The medical billing service should be permanently deleting the Claim File from their desktop to remain HIPAA compliant

If the medical billing service has the contract with Office Ally Clearinghouse and you are the medical office contacting them to gain access they will most likely forward you on to your medical billing service to get a user name/password. Office Ally Medical Claim Clearinghouses contract is with the billing service and not you.

If you are not on speaking terms with your medical billing service or you would rather they not know you are trying to log into Office Ally Clearinghouse than you will need to work this through another angle.

Your other option and one that you have more control over if you cannot get a user name and password into Office Ally's Clearinghouse.

The doctor has access to setting up user names/passwords with all health insurance carriers they are contracted with including BCBS, Cigna, Aetna, UHC, Humana and many more. This is the same place that you might use to check patient eligibility online but instead of clicking on the eligibility click on the claim status section.

Side Note: If the billing service has registered the doctors on these websites you will need to ask them to give you user names/passwords to access. If they ask why you need access (and they shouldn't but if they do) explain the doctor would like to monitor new coding updates, releases, fee schedules and that the front office needs access to check patients eligibility and pre-authorizations. Notify the billing service that you would like them to keep you updated with the most current user names/passwords for each health insurance carrier.

How to use your Health Insurance Carriers websites to track what your billing service is doing?

Use the online claim status screens to track your patients and identify how long it takes from the time you give the claims, medical records information to your billing service until it gets accepted by your health insurance carrier. Plus you can check for denials etc. If the patients claims are not on file with the health insurance carrier than it means that the billing service is having issues submitting claims through Office Ally (they are kicked out because information is being sent incorrectly so they do not send on to the Health Insurance Carrier).

For a list of additional Articles I have written please check out this website and scroll down until you get to the Electronic Medical Billing Clearinghouses section.

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Oregon Medicaid MMIS Updates on Claim and ERA issues

Oregon Medicaid Health Insurance was recently converted to a new MMIS system and the bugs have already started to reveal themselves. Oregon Medicaid Health Insurance has identified issues with the Electronic Remittance Advice and some claim processing issues.

Some medical offices and hospitals are experiencing problems with inconsistent denial codes, medical claims dropping out of the system, missing electronic remittance advice and problems with weekly electronic funds transfers.

The transition to the new MMIS system happened in Mid-December. If this is happening to you please be aware that Medicaid is aware of most problems and are working to resolve these issues. If you feel your issue is new please contact Medicaid and notify them of the problem.

Medical Tags: Clearinghouse, Medicaid of Oregon, Health insurance claims billing issues, Electronic Remittance Advice issues, medical claims billing and coding issues

Medical Clearinghouse Reports Simplified

Have you ever been confused over the Clearinghouse Reporting system? Well, let me try and break it down in the most simplified terms:

A few years ago most medical offices were ecstatic about being able to send electronic claims (NO MORE PAPER - YEAH) but now insurance carriers are sending clearinghouses so much more information. Clearinghouses can choose to supply/support different features based on their clients needs. Identify with your Clearinghouse which reports they can supply to you.

Reports:
270 Electronic patient Eligibility Inquiry
271 Electronic patient Eligibility Response (does the patient have insurance)
275 Documentation/Medical Attachment (i.e. Texas Workers Compensation claims)
276 Claim Status Inquiry
277 Claim Status Response (is claim on file, was claim paid, why is claim pending)
278 Prior Authorization and Service Authorization
820 Remittance Advice for Managed Care Organizations
834 Medicaid Enrollment for Managed Care Organizations
835 Remittance Advice (electronic explanation of benefits or EOB)
837P Professional Health Care Claim (CMS-1500 format or HCFA 1500 format)
837I Institutional Health Care Claim (UB04 or UB92 format)
837D Dental Health Care Claim
997 Acknowledgement of Claim Status

What you may not know is that Clearinghouses also supply additional services like:
Patient Address Verification
Patient Credit Verification
Patient Credit History
Patient Ability to Pay
Claim Scrubbing
Statements (ask them how long it takes for the clearinghouse to get the statements to the post office)
Collection Letters
Logos on Statements
Appointment Reminder Postcards
Custom Inserts
Financial Documents
Online Patient Portal
Reporting Options

I have found a wonderful website which reviews many of the clearinghouses for purchase. Please visit: http://www.medicalbillingsoftwarepro.com/Medical%20Billing%20Clearinghouses.html and click on the links to read more about the services they offer.

Post a comment if you would like me to answer any follow up questions! Or if you have additional questions on Electronic Medical Billing and Claims then click here medical claims electronic billing

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Clearinghouse that receive Online Claim Status 276/277 reports

A medical billing service with over 150 providers / 80 data bases asked me one day on my thoughts of creating a medical software that would search medical insurance carriers websites for medical claim status. I explained to him that last year I had the same thoughts when I was frustrated checking online claim status for so many patients. I thought if I had a software system that could go out, log in to these medical insurance carriers websites and check for me it would save me 100's of hours.

Well, that got me to thinking that their has to be a better way and I also figured someone else must surely have already created it. So I searched high and low until I found this website: Practice Management Software Reviews and I was searching through the navigational bar and found a link for Medical Clearinghouse Reviews. I began clicking on the links to read more about the clearinghouses when I read that these clearinghouses could check claim status for those claims you submitted electronically through them. I was in awe!

So, I asked the VP of the billing service what clearinghouse he uses and he said RelayHealth. I told him he was in luck! His clearinghouse does receive the 276/277 reports . He mentioned that his practice management software is interfaced with RelayHealth so I told him to follow up with his PM and ask them to create a interface to receive the claim status reports from RelayHealth. He was excited knowing this was an option that he can present to his software vendor!

How Does this help for big or small medical practices -
Picture this - the client bills out over 16,000 claims a month. Of those 16,000 claims lets assume that all are being submitted electronically. He has claim scrubber and other tools that assists him in sending 95% of his claims clean resulting in a average of 5% denials or 800 denials a month. What if he had a tool that could search for those 800 claims within minutes and notify his billing office the status of the claim i.e.

• claim pending
• claim denied for XYZ
• claim paid with check #, $ amount and mailed to
• claim not on file
• claim processed on XX/XX/20xx and check is coming

Within minutes his billers know what is expected and can promptly work those denials without having to first call for the status of ALL claims. Just think how this can change your business dynamics!

Clearinghouses that I was able to find that accepted the 276/277 reports.

Expect more /get more!

ANS Affiliated Network Services
Instantly Track and report on claims status

Availity ThinEDI software
Manage accounts receivable by checking claim status for processed claims

Electronicclaim.net
Get check numbers and check dates on paid electronic claims
Detailed status of each outstanding electronic claim
Uses 837Direct to generate electronic Status Requests
Easy to use Wizard to generate 276 electronic claim Status Requests
837 electronic claim Batch Transmissions can be confirmed
Inquire on the Status of any outstanding electronic claims
Inquire on the status of multiple electronic claim batches

Emdeon
With Emdeon Vision, payers have the ability to perform claim searches, verify claim status and generate a variety of claim trending and summary reports

ENS Electronic Networking Systems
ECT allows you to quickly search any claims you have sent and ensure they were properly received by the insurance payer within seconds.
Greatly reduce follow-up time and phone work tracking unpaid claims
Track all claims online using quick or advanced search options
Easily print or view the results on your screen
Real-time response, accessed via the Internet

Gateway EDI Clearinghouse
Unlimited Individual Claims Status Inquiry

InstaMed clearinghouse
Get answers to your claim submissions in seconds, including claim acceptance, pre-adjudication results on eligibility, clinical coding verifications, and WEDI levels 1-7 claim edits.

Medavant
To find your claim's status at the payer, run a Claim Status Inquiry (CSI) for real-time information at every stage of the adjudication process.

Medx12
The MedX12 Claim Status Inquiry feature allows physicians and other healthcare providers to easily access up-to-date information on previously filed claims. By providing you with the most current status received from payers, we help you manage your accounts receivable and reduce the costs incurred in contacting the payer for an updated status.

Navinet
easily and efficiently submit, track, check the status of claims, and reconcile reports, electronically.

PayerPath
efficiently submit online, real-time inquiries to payers about the status of a transmitted health insurance claim. Even better, you'll reduce the amount of time spent manually checking a health insurance claim status while at the same time improve record keeping.

RelayHealth
RelayHealth’s website does not specify all of the reports they support however; they do offer them

ZirMed
Our Claims Tracking feature allows you to follow the progress of the claim every step of the way


For more information on how to Read EDI Reports:
How to read EDI clearinghouse reports
Clearinghouse EDI Reports
Clearinghouse Online Claim Status EDI Reports


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Medicare NPI numbers and Clearinghouses

Medicare has identified that some clearinghouses are stripping NPI numbers when forwarding the claims on to Medicare. This of course has a huge consequence to the providers including a false sense of security that your claims are actually going to the carrier correctly and without the NPI these claims will not count towards PQRI participation for eligible professionals (losing your Bonus potential).

If you are using ERA (electronic remittance advice) through your clearinghouse don't be fooled just because you see the NPI number on the ERA form. They have also identified that clearinghouses are "adding" these to the ERA even if the claim wasn't transmitted with them.

Medicare of course can not tell you "which" clearinghouses are doing this so they recommend you call your clearinghouse and ask them. Of coure, are clearinghouses going to actually tell us the truth????

Well, for those who may care I use McKesson and I am getting my Medicare payments with using my NPI number on my claims. If you are looking to switch to another clearinghouse McKesson is really good at what they do. Great support, great knowledge and quick turn around on cases. I do trust McKesson with my claims and ERA's.

Interested in additional Online Medical Billing and Coding articles? Then click out Billing and Coding Online Courses

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