3 new payer rules—and what they mean for you

New rules that took effect in January are expected to simplify the claims process for Medicare and other health plans.

ODs who receive funds and remittance advice electronically are likely to notice some changes to how third-party commercial payers handle claims. Below are three examples of how new regulations should affect practices and hopefully ease the administrative burdens associated with claims:

1. Denial codes are standardized

“Receiving correct payment will be much smoother.”

Health plans previously used a variety of denial codes to explain why a claim was either denied or not processed. In turn, providers and staff spent a great deal of time and resources trying to figure out why a claim hadn't been processed appropriately.

Under the new regulations, plans must use standard code combinations to explain claim denials and payment.

Some ODs say this will help streamline the process of getting paid.

After years of having to deal with different denial code sets, new administrative simplification requirements "should make the explanation of benefits easier to understand. Receiving correct payment will be much smoother," says Harvey Richman, O.D., a member of the AOA Third Party Center Executive Committee.

Periodically, members of the health care industry such as hospitals, health systems, providers, and professional organizations will be invited to identify changes and additions needed to the core list of codes. As part of its interest in improving code explanations, the AOA welcomes the opportunity to provide feedback during this process.

2. Electronic transaction enrollment is simplified

In the past, the process for enrolling providers in Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT) programs also lacked consistency. EFT allows for a provider's claims payments to be electronically deposited into a bank account. ERA is an electronic communication that contains claim payment information, and it can be viewed or printed.

To get signed up for these programs, ODs and other providers had to fill out different forms and go through entirely different processes, which was both time-consuming and frustrating.

Health plans are now required to collect the same data from all providers for enrolling in ERA and EFT. In addition, health plans must offer electronic enrollment for both programs.

Optometrists already enrolled in ERA and EFT will not be affected by these changes.

3. Tracking payments and remittance is easier

Providers often experience bookkeeping problems when there is a significant time lapse between when a remittance is received and when funds are made available. Starting this year, payment and remittance must arrive within three days of one another. Trace numbers will be available for providers to track payment to remittance.

Health plans that are not compliant with these changes will experience financial penalties no later than April 1.

Optometrists can view a timeline of changes to these claims processing rules or access an overview of the rules from the non-profit CAQH.

February 20, 2014

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