DRG CODING ADVISOR
New claims clearinghouse may begin this summer
But will it really speed payments?
With a lot of hoopla last year, seven large insurers announced they were collaborating to form a new Internet-based electronic claims clearing house to process health care bills. The San Diego-based MedUnite says its system will permit practices to securely submit about half a dozen health care administrative transactions and receive responses in real time over the Internet. The start-up is funded by Aetna U.S. Healthcare, Anthem Inc., CIGNA HealthCare, Health Net Inc., Oxford Health Plans, PacifiCare Health Systems, and WellPoint Health Networks.
Once the pilot phase is over, MedUnite hopes for a nationwide rollout this summer. When fully operational, practices will be able to submit paperwork for claims, claim status, eligibility verification, benefits determination, patient referrals, and treatment authorization for a flat monthly fee.
MedUnite’s CEO, David Cox, says one advantage of the system is that it will be able to immediately tell doctors whether a claim they have submitted is "clean" — contains no errors — rather than have to wait for the traditional review process, which is typically 14 days, before learning if there are any problems with a claim. However, since MedUnite clients will not be paid electronically, at least at first, they must still wait for snail mail to bring their money.
If you are filing claims electronically, you probably use a so-called claims clearinghouse to process your submission. These clearinghouses "edit" and format the claims according to individual insurers’ standards. If a claim contains "technical errors" —- i.e., it can’t be read by insurers’ information systems or data elements are missing — the claim is rejected and must be resubmitted.
Claims that are clean are forwarded to the insurer in question where they are edited or reviewed for patient-specific criteria, including patient eligibility. If the insurer has a question, or feels the claim has not been properly formatted or documented, it gets kicked back for correction. As a result, it is often several weeks after submission before a practice learns a claim is not going to be paid. According to MedUnite, only about half of all claims submitted to insurers are considered clean.
Many experts says the real advantage of being able to file claims electronically will come when physicians are able adjudicate claims on-line in real time with insurers — then be paid electronically. Such a system would mean practices could depend on receiving their money within a few days after a claim is submitted, instead of the average 45 days —or more — it takes now.
Indeed, Empire Blue Cross Blue Shield of New York says it will soon test a program in which it will pay claims electronically within 48 hours. Other insurers are considering using the e-mail systems to handle reimbursement.
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