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Electronic Transaction Toolkits for Administrative Simplification

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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.

Electronic Transaction Guidance

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.

    Prior Authorization Toolkit

    Prior authorization is a health plan cost-control process requiring providers to obtain approval before performing a service to qualify for payment. Health insurers frequently require prior authorizations for pharmaceuticals, durable medical equipment and medical services. 

    The inefficiency and lack of transparency associated with prior authorization cost physician practices time and money. The AMA believes that prior authorization should be greatly reduced and when used, should utilize a standardized, automated process that will minimize the burden placed upon both physicians and the plans themselves.

    Given the fact that health plans will likely continue to use prior authorization as a resource utilization control for the foreseeable future, the AMA offers the following resources to help minimize the impact of prior authorization on practices in the current environment.

    Learn more about the AMA’s efforts to reduce the time and money wasted on prior authorization.

    Electronic Payment Toolkits

    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 Remittance Advice (ERA) Toolkit

    Learn how to efficiently reconcile payments and make the most of this standard electronic transaction:

    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

    LinkedIn Group

    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.

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