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PubMed1998

Payers required to adopt standardized electronic claims processing.

The Health Insurance Portability and Accountability Act of 1996 requires most claims payers to support electronic claims processing and uniform national standards for code sets and identifiers to streamline healthcare administration. The law will penalize payers that do not support the standards and are not prepared to conduct business electronically by the year 2000. Many providers may qualify as claims payers and, thus, will be subject to penalties if they do not adopt EDI for the transactions required by the Act. Providers also will have greater opportunity to eliminate paper, speed claims payments, and cut administrative overhead. Both providers and payers will have new guidelines for privacy and confidentiality, and violation of these guidelines will result in significant penalties. Consequently, all providers should become familiar with the legislation and evaluate their EDI strategy in light of new opportunities and responsibilities.

Chronology as Topic↗
PubMed1998

Real-time claims resolution. Re-engineering how we process and pay for healthcare.

UNLABELLED: A Preferred Provider Organization with about 9,000 providers in three states. PROBLEM: A fragmented and confusing healthcare payment and processing system, which ultimately hurts everyone, the patient, the provider and the payor. SOLUTION: Create a real-time claims resolution system which links everyone for quick payment of the claim at the point of service. RESULTS: Reduces paper and accelerates the claims cycle. KEYS TO SUCCESS: "Re-engineer the current system of processing and paying healthcare claims with a business model that economically benefits all parties."

Evaluation Studies as Topic↗
PubMed1998

Designing an internal audit process for physician billing compliance.

An internal audit process is central to an effective compliance program. When based on pertinent Federal regulatory guidelines and executed by staff with appropriate technical expertise, an internal audit limits opportunities for noncompliant physician billing and reduces the risk of incurring financial penalties. The design of an effective internal audit process will incorporate uniform internal audit procedures, communication mechanisms, and educational initiatives to correct any deficiencies that are identified. For healthcare organizations that are involved with physician group practices, review of physician documentation is particularly important. This review provides essential information on potential areas of risk and offers a focus for future education of physicians regarding appropriate billing and documentation.

Communication↗
PubMed1987

Communications between insurers and providers.

Physicians are frequently distressed by their communication with insurers. This article describes the process insurers utilize to collect data, set reimbursement rates, and utilize peer review.

Communication↗
PubMed1999

Falling behind in the payment game. Providers are feeling squeezed by HMOs that don't pay on time and keep changing the rules.

When hospitals provide services, they naturally expect to be paid. But providers are waiting longer and longer for payment from HMOs, sometimes 90 to 120 days, putting the squeeze on cash flow. The problem has led states to enact prompt-payment laws. Health plans defend their record, saying hospitals' billing mistakes and antiquated computer systems are often to blame for the tardy payments.

Accounts Payable and Receivable↗
PubMed1999

Insurance policies may cover costs of False Claims Act litigation.

Expenses associated with the defense of a False Claims Act investigation or lawsuit may be covered by insurance. Such coverage may be available through a general liability policy, or in the case of not-for-profit organizations, through a provision added to the organization's directors and officers policy. In either instance, the extent of coverage is determined by the language used in the policy and state law governing interpretation of the insurance policy.

Costs and Cost Analysis↗