The ability to submit claims electronically is wonderful. It has sped up the reimbursement process to days instead of weeks. One of my favorite features is the almost instant claim rejection. I know seeing “favorite” and “rejection” in the same sentence sounds cuckoo, but listen to my reasoning.
Before electronic claims, if you sent in a paper claim on an expired policy, to the wrong primary payer, with wrong data like date of birth, or other errors, it took weeks to get the rejection. In the meantime, you could have been providing hundreds or thousands of dollars of services to the patient thinking all was well.
Many Revenue Cycle Management (RCM) systems like Iridium Suite will put your claim data through a front end “scrubber” to quickly identify errors before transmitting the claims to the automated clearinghouse (ACH).
Once claims have been transmitted to the ACH, they are checked against claims formatting standards to identify issues before they transmit claims on to the payer. If any issues arise there, the claim will be rejected almost immediately with the issue details sent back to Iridium Suite for investigation by the medical biller. Corrections can be made right away and a new corrected claim sent off for quick processing.
An example of a clearinghouse level rejection can be COB claim is out of balance. This indicates the electronic primary EOB attached to the secondary claim does not match the data on the claim. If this claim had been sent on paper, it would probably take at least 30 days to receive the rejection. This has immediate implications on the cash flow of the medical practice.
Once claims pass the ACH audit, they will transmit them onto the appropriate payer(s). The payers perform an initial analysis of data on the claim to determine if it can be passed on for processing. If an issue is identified, the rejection message returns back to the RCM via the ACH.
An example of a very common payer rejection is for an ineligible patient. Again, the biller is notified usually within 24 hours of transmittal and can immediately begin to investigate the proper payer coverage instead of waiting for the paper claims processing timeline.
Iridium Suite even has an automated “alert” icon that identifies to the biller that there are electronic claims that were rejected.
Another bonus to this front end rejection is that it prevents a denied claim that then has to go through a tedious “corrected claim” process at the payer. The reimbursement for those can take months slowing down your flow of revenue and reflecting poorly in accounts receivables aging reports.
See, I am not crazy. There are many advantages of the electronic claims rejection process in regards to your medical practice workflow and speed of reimbursements.