Practice Management Alert

Several payers are offering real-time claims adjudication -- are you taking full advantage yet?

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.

Move Beyond Claim Estimates

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, Okla., and editor of the HIT Transition Web log (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."

Capture Patient Payment Right Away

Faster patient collections tops the list of pros for using RTCA. When you perform real-time adjudication while the patient is still in the office, you-re more likely to collect the payment the patient is responsible for.

"You can immediately find out if the patient has 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, N.C. "It's just like every other service in America -- you buy something, you pay for it, you leave," she adds.

Patient plus: 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. "One of the huge benefits, therefore, especially if there's a denial, is that there is a real person with real billing knowledge right there explaining to the patient what happened with the claim and how to fix it," Davis-Jacobsen says.

More good news: By implementing RTCA, you-ll also reduce your office's claims rework. The billing staff in your office will have fewer problems and fewer denials to contend with since real-time adjudication immediately responds with the status of the claim and you can handle corrections right away, which will improve office efficiency, Sterling says.

"At the first X12/WEDI conference, Robert Barbour from Montefiore presented that the labor savings from RTCA is about $10 per claim," Kazzaz says.

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.

Caution: RTCA doesn't necessarily mean real-time payment. "Instead it's like getting an immediate claims status report or remittance advice, with the corresponding check or electronic deposit to follow," Jensen says.

Payers benefit, too: "So much of patient payables go to bad debt, payers are afraid providers will come back next year and demand contract concessions for all the lost revenue," Jensen says. With on-the-spot patient collections, payers don't need to worry about this as much.

"From the payer perspective, RTCA can save money by decreasing the cost of managing bad claims and minimizing issues with their subscribers," Sterling adds.

Weigh the Downsides, Too

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.

A key challenge for billers will be to integrate real-time adjudication into how their billing systems operate, Sterling says. You may have to enter claims information twice -- once in the Web portal and once in your billing software. Some billing software companies, however, are beginning to build real-time adjudication capabilities into software updates and programs, Jensen adds.

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."

Audioconference Offers More Information

To learn more about RTCA, sign up for the audioconference "Faster Payment, Fewer Denials ... Is RTCA Too Good to Be True?" led by Doral Davis-Jacobsen, BHS, MBA, CMPE, on June 5 at 1 pm EST. You can visit http://audioeducator.com or call (800) 508-2582 for more details or to sign up.