The AMA is committed to reducing administrative burdens on practices. Physicians and practice staff spend hours dealing with complex issues surrounding the insurance claim payment process, including prior authorizations, patient eligibility inquiries, claim filing and payment reconciliation, costing the practice money and time that could be better spent on patient care.
Physicians and their staff can reduce the time spent on these burdensome processes by implementing standard electronic health care transactions to complete practice revenue functions. The AMA’s electronic transaction toolkits offer a wealth of information to help practices transition to electronic processes and improve the efficiency of their business.
The following AMA-developed resources provide an overview of the standard electronic transactions mandated by the Health Insurance Portability and Accountability Act (HIPAA), offer implementation guidance and detail actions practices can take if they encounter health plan compliance issues.
- Understanding the HIPAA standard transactions: The HIPAA Transactions and Code Set Rule (PDF)
- Questions to ask a health insurer before enrolling in an electronic transactions program (PDF)
- Questions to ask a billing service before enrolling in an electronic transactions program (PDF)
- Questions to ask a clearinghouse before enrolling in an electronic transactions program (PDF)
- Compliance in standard electronic transactions: Responsibilities of health plans and physicians (PDF)
Prior authorization is a health plan cost-control process requiring providers to obtain approval before performing a service to qualify for payment.
The AMA believes that the overall volume of medical services and drugs requiring prior authorization should be greatly reduced.
In recent years, health plans have shifted from paper checks to electronic methods of physician payment. Health plans are required to offer electronic funds transfer (EFT) payments using the Automated Clearing House (ACH) Network to practices that request this method of claims payment.
Additionally, many health plans have started paying physicians through virtual credit cards (VCCs), which are processed using standard credit card technology but can result in significant lost revenue for practices. The following resources provide information and guidance to physicians on electronic payments.
- Electronic funds transfer toolkit (PDF)
- The effect of health plan virtual credit card payments on physician practices (PDF)
- Know your rights and make ACH EFT work for your practice (PDF)
- CMS guidance on VCCs, EFT/ERA and business associates (PDF)
Electronic Remittance Advice (ERA) toolkit
Learn how to efficiently reconcile payments and make the most of this standard electronic transaction:
- Getting started with ERA (PDF)
- Critical conversations with trading partners about ERA (PDF)
- ERA processing tips (PDF)
Electronic eligibility verification toolkit
Use the following resources to leverage the electronic eligibility transaction to determine patient insurance coverage and benefits in a timely and less burdensome manner.
Electronic claims toolkit
The AMA, in collaboration with the Medical Group Management Association, developed the Electronic Claims Toolkit (PDF) to help physicians and practice staff understand the electronic claim submission process and maximize the benefits and efficiencies of an automated process.
Workers’ compensation and auto injury toolkit
This toolkit helps practices implement electronic processes to improve the efficiency of property and casualty (workers' compensation and auto injury) billing.
Physician practices can improve efficiency and reduce costs by implementing practice management system software that can automate a significant amount of revenue cycle functions. To help practices evaluate their needs and make informed choices when selecting a practice management system, the AMA and the Medical Group Management Association have created a collection of informational resources.
The AMA Administrative Simplification LinkedIn group is designed to provide updates and encourage dialogue on administrative issues affecting physician practices, including automation using electronic standards and operating rules, prior authorization standardization and reform, and regulatory developments. Physicians, practice staff and other interested stakeholders are encouraged to join.