Medicare Compliance & Reimbursement

You may think claims approval in minutes can only happen in your billing dreams, but those dreams may soon come true. Real-time claims adjudication (RTCA) is beginning to catch on in practices, and more payers are offering you this cost-saving option. Here's what you need to know to find out if your office should jump on the RTCA bandwagon.

UnitedHealthcare, Humana, Tricare and Blue Cross Blue Shield of South Carolina are just a few of the payers that offer RTCA to their physician clients. RTCA allows you to view, at the time of service, how much insurance will pay and how much a patient will owe.

RTCA is a growing trend among payers and practices. "Many of the major payers and the patient management systems are well on the way toward piloting RTCA," says Daniel Kazzaz, chair of Accredited Standards Committee (ASC) X12 and president of Rapid Data Interchange in Bethesda, MD.

How it works: Before the patient leaves your office, you submit the claim, complete with CPT and ICD-9 diagnosis codes, using a Web portal. "RTCA refers to a technology that allows a provider to submit a claim electronically and receive an immediate, definitive response from the payer," says Martin Jensen, COO and chief analyst for the Healthcare IT Transition Group in Tulsa, OK, and editor of the HIT Transition Web log (http://www.blog.hittransition.com). "It's not the same as a claims estimator. The goal is to get the final result, less any contractual adjustments and exclusions."

"You can immediately find out if patients have met their deductible and thereby calculate patient responsibility," says Ron Sterling, president of Sterling Solutions Ltd. in Silver Spring, MD.

Being able to correct any errors and instantly resubmit will help your AR, Jensen adds.

By handing the patient his explanation of benefits at the time of service and then collecting patient payments in this way, you avoid having to send statements through the mail and having to follow up one or more times to collect, says Doral Davis-Jacobsen, BHS, MBA, CMPE, manager of the physician services consulting unit of Dixon Hughes PLLC in Asheville, NC.

When the patient receives his explanation of benefits at the time of service, he's able to ask questions if he doesn't understand something on the statement.

Bonus: You'll also see a reduction in the number of days your claim goes unpaid. The faster the payer recognizes your correct claim, the faster you'll get paid. Payment is normally within 24 hours, Davis-Jacobsen says. Plus, there's no cost to use the service. RTCA also creates a great confirmation of timely filing.

Potential pitfall: Before you implement RTCA, you should consider the potential cons as well as the benefits.

"The biggest downside right now is that most of the implementations are via Web portal, rather than being integrated with the various billing applications," Jensen says. This means that you may have to sign in to different portals for each of your payers.

In addition: Using RTCA requires changes in your office processes and sometimes changes in software systems. "The process of dealing in batches on a daily basis will be replaced by real-time claims adjudication and supporting processes," Sterling says. "Billers need to change their operations and services to capitalize on RTCA to improve operations and efficiency."

The non-par difference: What happens if your practice does not have a contract with the patient's insurance? "In general, the practice must collect the entire amount from the patient and the patient must submit the claim on paper," Kazzaz says. "If we assume for a moment that RTCA will support both participating and non-participating providers, then the benefit of RTCA extends to the patient. The patient avoids the expense and challenge of collecting from their insurance company."