Thursday, August 14, 2008

Submitting Insurance Claims

I recently went to the optometrist and they refused to submit any claims information electronically for me. I had to do it by snail-mail. As a result (in addition to the fact that they are inconsiderate of my time) I switched providers. While the topic of electronic claims submission may be foreign to public pay systems, submitting claims to insurance companies is common place in private pay. When patients register, insurance information is recorded in the management software and at the end of the appointment treatment codes and fees are sent electronically to the insurance companies. In our office, the patients still pay for treatment but we submit the claims whenever possible. Reliably submitting the claims information improves both patient satisfaction and cash flow for the business.


Assuming that electronically submitting claims data is important to both practice and patient how should a manager monitor the transactions? The good news, is that insurance companies provide immediate electronic confirmation of data received and if there is an error, it is recorded with the information.


"Claim Rejected ERROR ID 54675 Claimant Registration Number invalid"


By data mining records, managers can monitor the error rate of submitted claims based on which administrator is submitting it. The chart below shows an example of this


Employees 21 and 20 have error rates above 1 standard deviation of the other employees. Interesting, the error rate correlates to performance evaluations of employees but the volume of submitted claims does not seem to correlate to the error rate. In other words, administrators that submit more claims are just as likely to create an error.


One word of caution, the error rate is dependant on the type of patient that the administrator is assisting. In the chart, employees 1 and 2 routinly submit claims for patients that return for regular appointments, whereas other employees are submitting data for patients that may have only 1 or 2 claims in our office.


The EDI error rate seems to be another measure of employee performance (for similiar patient groups). Using it as a benchmark may be an objective means to improve patient satisfaction and practice cash flow.

2 comments:

Hans Skariah, B.Sc. DMD said...

Ian, are there any studies(evidence)that support collecting the entire fee at treatment completion vs. collecting just the co-pay . Would treatment acceptance rise? Would efficiency rise/fall? Would the savings in transaction fees be eaten by increased administration costs?

Ian Furst http://www.waittimes.blogspot.com said...

Hey Hans,

There is good evidence (NEJM) that any copay decreases use (acceptance). Our data suggests that the greater the copay the lower the acceptance (I just learned to data mine this stuff so I'll post another one on how well/poorly it correlates) but I can't say whether or not copay alone vs entire fee will change acceptance.

Our policy is to collect the entire fee but allow deferred payment until the insurance cheque arrives (eg post-dated cheques, CC).

With that our bad debt rate is <2%. We often talk about entire fee at time of treatment (even deposit for larger treatment) but we calculate that the decrease in acceptance rate will be >2% (est about 10% but tough to calculate could be 5-25%). Our assessment of the situation is that entire fee with basic deferred payment option results in high acceptance rate and low bad debt.