e-claims: A new twist in electronic processing

Despite Dr. Bill Dickerson's best advice, and that of cosmetic dentists and others, the majority of practitioners still work with insurance companies.

by Paul Feuerstein, DMD

Despite Dr. Bill Dickerson's best advice, and that of cosmetic dentists and others, the majority of practitioners still work with insurance companies. Those readers with insurance-free practices can skip to other articles in this journal. However, for the rest of you, I have a story to tell about insurance claims processing.

When I installed my first dental computer in 1978, I can remember my staff's excitement as we ran our first end-of-day report. We hit a few keys and — presto! — 10 insurance forms printed out. Everything was legible, and patient names were spelled correctly. The forms listed the proper procedure codes, and all fees were totaled correctly.

We sent the forms out daily, and, to our delight, received payments sooner than usual. We still received the occasional rejection due to ineligible codes or a missing social security number. These were mostly due to our own input errors. Still, we saved a lot of time, and if we bundled several claims together in one envelope, we saved on postage.

Enter e-claims

As the Internet advanced, it seemed only logical that we fax or email the claims to the insurance companies. If we sent a file to a printer, it could go to an insurance company. If we sent a claim via fax, then the insurance company could scan it and bring in the information by character recognition software. However, both methods had problems. At the time, there were at least 50 practice-management software companies — with 50 incompatible formats. A Dentrix user, for example, could not read data from Softdent. Thus, the computer format of the insurance claim was coded differently.

On the other side, each insurance company had its own individual, secure format. They were not willing to have each of the 50 practice-management (PM) companies explain their formats and spend hours collecting and translating the data. This gave rise to the "clearinghouse." Companies such as WebMD/ Envoy evolved that could accept any format from any PM software and convert it to one that was acceptable to each insurance company. Certain errors could be captured and returned quickly to the dentist before becoming lost in the system. Taking this a step further, the integrated package could check claims before transmittal, which saved even more time. In a situation where no software was available — for example, a union local — the clearinghouse could actually print out and mail a form.

Now there is a system where this process happens instantaneously. E-claims are the next wave in dental insurance claims processing. There's no comparison to paper claims. E-claims allow immediate claims processing, while a mailed form takes weeks to process. Don't let outdated software or hardware stop you from investing in this technology; the time savings and efficiency alone will more than offset the expense to upgrade your systems.

An extension of e-claims is electronic submission of radiographs, photos, perio charts, and other documents. Once again, a clearinghouse is necessary due to the array of digital formats in photographs and images. NEA and Tigerview have software that allows the office to email images to them. An "image number" is assigned to each one. When a claim is sent that requires an image, a note is made on the form referencing the image number (for example, NEA1234) instead of actually enclosing them. When the insurance company receives the claim, they actually go to the image clearinghouse and access the image, which is now in an acceptable format. (Incidentally, these images are never lost in the mail!) As an aside, NEA has begun a program called "Plus" that allows dentists to share images over the Internet using their clearinghouse. Dentists post the images by giving a secure password to the dentist who will view the images. Transcend Online also has a successful transfer program that helps to speed up and improve relationships — especially when rapid referrals are necessary.

Previously, when we needed information about a patient's insurance coverage, we had to first call the company and then enter the information into the patient's file in the computer. This allowed us to give the patient a rough estimate of coverage when we sent the bill or collected a copayment. Now, most practice-management systems have a vehicle to track patient insurance benefits.

Some use a manual system where the office staff must input the policy parameters into the system. Others integrate with services such as Trojan that give more precise information. For offices that choose to accept insurance assignment, these systems allow a better relationship with those patients who want to maximize their benefits.

While some of these systems can help with predetermination — or "pre" — of benefits, it is still more accurate to get this information from the insurance company. In the past, an office printed the pre, stuffed it in an envelope with some radiographs and barely legible copies or photos, and send them off, hoping to get the information back before the patient's benefits ran out.

The insurance company then would have these documents keyed in, reviewed, and sent back to the dental office with either a direct answer or a request for further information. Unfortunately, when patients must wait for the pre, they often conveniently forget to make an appointment at all.

As this system has evolved, the PM companies have made enhancements to their software and have developed tighter relationships with the clearinghouses. They also have increased the error detection capabilities in the office software and at their own claims centers. The companies have staff available to help the dental offices with claims questions. In addition, they now are integrating image attachments to allow direct submission from the patient files.

A new technological step is the use of an insurance company Web site. With many offices now equipped with high-speed Internet access, it's a rapid method of checking patient benefits and eligibility. Instant predeterminations should be available in the near future as practice-management companies merge their technology with that of the insurance industry. In the near future, we also will see electronic payment by direct deposit, which will cut the turnaround to as little as one or two days.

Free e-claims?

The latest incarnation began in late 2001. MetLife set up a program with Practice Connect (DentalXchange) and began offering free e-claims under "Claims Connect." MetLife contends that if more dentists sign up for e-claims, it can reduce its costs enough to eliminate the fees charged to dentists. Since MetLife also is larger than any of the dental companies, the company claims to have the resources to easily take care of customer service. It also is trying to recruit other insurance companies such as Aetna to join this project.

This concept has troubled both practice-management companies and clearinghouses and also has caused a great deal of confusion for dentists. Is this new process too good to be true? Practice-management companies have challenged Claims Connect by showing the value of the paid service. One clearly states: "There are hard costs associated with printing paper claims, processing electronic claims, and providing support using qualified and experienced technical support personnel. Somebody has to pay these costs, and a failure to address technical support requirements eventually impacts the quality of services provided and the financial viability of the company."

Claims Connect replies that it not only gives quality service, but has very few inquiries due to the nature of the system. The goal of Claims Connect is to have claims processed in "real time;" i.e., while the patient is still in the office, which will allow the staff to ask for an accurate copayment. At this time, Claims Connect has taken the lead in direct integration with the insurance industry.

Unfortunately, this discussion has become very emotional among the players. Articles and debates have begun to focus on corporate issues as opposed to the dentists' benefit. If you currently send your claims electronically, be sure and check with your current provider to see what the impact would be if you switched to the free system.

As with any product, there are both ecstatic and unhappy users. Be sure and look at the value of what you currently are receiving vs. what is being offered. A mere .50 cents adds up to about $75 per month in an average office, which some say is a small price to pay for the services rendered. However, others state that such fees are unnecessary. One consideration is that all of this data sailing around on the Internet has to be secure by next April, according to HIPAA rules. But, that's a tale for another time ...

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