As part of its Administrative Simplification Rule, the Centers for Medicare & Medicaid Services (CMS) established standards to streamline communications between health care providers and health plans. But you may not know that these regulations can save your practice processing time and billing costs. All health plans are required to provide the functionality below – make sure your practice is benefiting!
Electronic Funds Transfer (EFT)
- Be aware that some insurers are sending payments in the form of virtual credit cards, which cost practices a transaction fee ranging from 1.9% to 3% or more of the transaction amount. If this is happening to you, you can request EFT instead, and health plans are required to comply.
- Health plans are required to offer physician practices the option of receiving payments via EFT using a national standard. If you’re still handling paper checks, this will be a huge time-saver for your practice!
- A recent MGMA poll indicated a new issue: one out of six providers is now being charged fees ranging from 2-5% for EFT payments from health plans. If you are in this group, we encourage you to contact the insurer and request “no-charge” EFT payments. CMS has not issued explicit guidance against this practice, but some health plans will eliminate these fees if you request it.
Electronic Remittance Advice (ERA)
- Health plans are required to provide ERAs designed to correlate with EFTs. When used together, practices can automate the matching of a payment with the remittance, eliminating a time-consuming manual process.
Real-time patient eligibility
- Health plans are required to provide real-time online access to patient eligibility information, including:
- Deductibles, co-pays, coinsurance, in/out of network variances.
- Coverage information for specific service categories.
- This enables you to verify insurance benefits, co-pays, etc. prior to the patient’s visit – so you can provide patients with an accurate estimate of their costs up front and collect these amounts at the time of visit. For more information on best practices for collections, check out our newly updated Collections Toolkit.
- Practice Management Committee members have reported that some insurers do not provide real-time access to benefits for allergy services. Unfortunately, allergy immunotherapy and other allergy-specific services are not a required category for real-time eligibility.
Real-time claims status
- Health plans must furnish real-time online access to claims status information.
What if a health plan you work with doesn’t comply with these standards? CMS has a new online tool practices can use to anonymously file a complaint with CMS. The Administrative Simplification Enforcement and Testing Tool (ASETT) also allows you to test transactions, both your own and your business partners’, for compliance.
For more tips on practice efficiency, check out our newly updated Practice Profitability toolkit. We have a wealth of suggestions, including smart staffing, how to take advantage of technology and how to optimize office space to improve workflow.