Many different options and providers exist for submitting claims electronically. Following are some of the basic features of full-service and self-service electronic claims:
"Full-service" Electronic Claims
Full-service electronic claims are filed on behalf of a psychologist by a third party-often a billing service. The psychologist is required only to send basic patient and service information to the billing service, which then develops and submits the claim directly to the appropriate insurer or to a health care claims clearinghouse.
How much does it cost? The billing service often retains a percentage of the total claim amount as payment for its services. The percentage retained often depends on the types of services provided, and can range anywhere from 4 to 15 percent of the total claim amount.
"Self-service" Electronic Claims
Self-service electronic claims are developed and submitted by a psychologist (or a member of the psychologist's staff) directly to a third-party payer or health care claims clearinghouse.
Practitioners who submit claims to only one or two payers may opt to submit their claims directly to the individual third-party payer using proprietary software provided by the payer.
However, practitioners who submit claims to many different third-party payers often find it most convenient to submit claims to a single clearinghouse, where the claims are sorted, formatted, checked for accuracy and transmitted to the appropriate payer. Options for submitting claims to a clearinghouse include:
Direct file submission. Some practitioners use their practice management software to submit claims to a clearinghouse. The practice management software creates an electronic file containing claims to be processed, and the file is sent to the clearinghouse through a secure connection via the telephone or Internet.
Direct data entry. Practitioners who are not comfortable using — or are not able to use — their practice management software to submit claims can still enjoy the benefits of submitting claims electronically. Using direct data entry, the practitioner or his or her staff member logs into a clearinghouse using a secure Internet connection, enters the provider, patient and claims information into a formatted webpage — often an electronic version of the HCFA 1500 — and submits the claim for processing. The clearinghouse can retain the patient, provider and claim information in a secure system so that the practitioner does not need to reenter all of the information if he or she files similar claims in the future.
Additional self-service claim submission options may be available for an additional cost, enabling practitioners to perform such functions as:
Check insurance information, such as patient eligibility, plan information and co-pay amounts
Convert patient statements into electronic format for download into practice management software
Check referrals, pre-certifications and authorizations online
Receive Electronic Remittance Advice (ERA) and electronic Explanation of Benefit (EOB) statements from participating payers to determine immediately when a claim is paid and for what amount.
The self-service option is often more economical than using a full-service billing service for solo practitioners and small practices, and provides the psychologist with an additional level of control over the sensitive personal information contained in a claim.
How much does it cost to submit self-service electronic claims? Pricing may be determined on a "per claim" basis, a flat fee or a combination of a regular flat fee plus per-claim fees. Pricing may also be different depending on whether claims are entered via direct data entry or a file is uploaded from practice management software.