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Medical Billing Services

Who we work with

Our medical billing services team works with mid-large size physician groups and health systems

You are leaving money on the table. We can almost guarantee it.

As reimbursements tighten up, patients bear a larger portion of their healthcare costs per year, revenue cycle management that’s based on rock solid systems, processes and procedures has become even more crucial. Your practice’s viability, sustainability and profitability depends on the performance of your billing department.

Whether you choose to do it in-house, outsource it to an RCM firm on-shore or offshore is ultimately your decision. We can consult and work with your team or transition the entire RCM process to our RCM center of excellence to provide you with the peace of mind that you are looking for.

Most provider groups that we start working with, seem to lack robust systems, processes and defined workflows to be as efficient and lean as possible while maximizing collection rates. We can start by looking at what you are collecting per $ claim submitted, what the industry benchmarks are, the steps needed for you to reach those goals.

We are huge fans of HFMA MAP keys – in case you are wondering. Trust us to handle your revenue cycle management processes – end to end.

How we work with you

We follow a transition process to ensure minimal disruption and do not believe in a “boil the ocean” approach.

  1. Our transition managers set up meetings with your in-house or outsourced billing department to understand the current processes.
  2. Our team analyzes the current financial health of your practice and comes up with a plan of attack based on where we find the most pressing needs to be.
  3. Our team creates a plan to first address the most pressing issues, makes process improvement suggestions, creates a plan of action.
  4. After getting approval on the plan and the associated KPIs, our team sets to actionable items on the plan.
  5. Thereafter, each week we measure progress against KPIs, adjust and fine tune as needed.
  6. As KPIs are attained, this also allows us to slowly transition over the workflow from your existing team.
  7. We rinse and repeat this process with your entire revenue cycle management workflow until both parties are satisfied of smooth functioning.
  8. Once a transition has been achieved, we hold our own team accountable to the same measures that your current team was held against. We continue reporting on the same KPIs as well.

What we can help with

Provider Enrollment and Credentialing

We find that quite a few of claims issues stem all the way upstream to provider credentialing and enrollment.

We have found situations where some providers in the same practice group are credentialed with some payers and some plans only. Some providers are contracted at varying rates as well – for the same payer, same plan, same location.

Overall, we create a provider credentialing matrix wherein we always keep ourselves and your practice abreast of what the credentialing status for each payer, plan, provider is.

This also allows us to ensure that we always know the par status before a claim is submitted. You’d be surprised at how much information you can glean by having such a provider/payer/plan matrix in front of you and how much money you might have been leaving on the table

We leverage a few of our technology solutions to help achieve the same and can help you with 855 forms, PECOS, CAQH.

Pre-certification (Authorization) & Insurance Eligibility Verification

  • We leverage our eligibility verification solutions in addition to using payer IVRs and payer CSRs to verify coverage on primary, tertiary, Medicaid etc
  • In conjunction with our patient contact center team, we reach out to patients & get updated insurance information (if anything has changed since their last visit)
  • Keep up-to-date/current member ID, group ID, coverage end and start dates, co-pay information etc
  • As needed, we also obtain pre-authorization codes and PCP referrals as needed
  • We not only stay up to date on patients’ issues with coverage or authorization but we also keep your team in the loop about the same.

Patient Demographic Entry

While insurance eligibility verifications is a crucial aspect of revenue cycle management, patient demographic entries play a big role in reducing denials downstream as well.

Our team ensures that there are no issues with patient demographics with respect to name, DOB, address, phone number, medical history, guarantors (if any), insurance details etc.

If any of these are missing or has been missed by your front desk, we ensure that our patient contact center team gets in touch with the patient to sort out the details.

This becomes very important if we want to avoid having to rework claims.

While a lot of this seems like manual data entry work, we actually employ several technologies to ensure proper collection of patient demographics data entry, verification of patient identity etc.

CPT and ICD-10 Coding

Some denials are rooted in CPT -> ICD10 coding. There’s no getting around that.

We work with your superbills and completed visit notes. While it is ideal if the ICD/CPT codes are noted in the same, it is not mandatory to do so.

Our team is equipped to work with your superbills to ensure that work can progress with as much or as little assistance as possible. We need to ensure and prevent any up/downcoding related challenges to avoid possible future denials.

Charge Entry

We work with your fee schedules and ensure that they are as per state/provider contracts.

Our team ensures that all patient demographics have been provided in the claim and are ready to be filed. After we do this, we ensure that we run it through a round of quality checks to ensure that our clean claims rate remains at the highest levels.

Claims Submission

First things first – we ensure that the claims are submitted electronically.

While we have met practices that do not do this, we strongly encourage our clients to submit claims electronically (we can help you with the set ups as well).

Should there be an insurance requirement for paper to be used, we can do the same with the clearing house.

Rejections are part of the day to day world of claims. While keeping our clean claims rates at the highest performant level, we will still see rejections for some reason or the other. This happens with everyone in this ever changing healthcare industry.

We ensure that rejections are corrected and resubmitted within 24 hours.

Payment Posting

Hopefully you are enrolled in EFT/ ERA to avoid delays in payments. If you are not, we ensure that your providers are EFT/ERA enrolled to reduce the time wasted on paper checks and payments.

We post and reconcile ERA / EOB / Denials on a daily basis.

We can work using your payment management system or we can also utilize our own. Either way, the net result is that your payments are posted at the earliest.

Account receivables follow up

Accounts receivables are broken down into buckets based on the age of the account. Our team analyzes the account receivable buckets and comes up with appropriate course(s) of action for each bucket.

Thereafter, we prioritize our plan and work accordingly to help you slice through your A/R and recover monies due at the earliest.

Typical to our communications plan, we keep you informed on a daily/weekly/monthly basis and also ensure that we have quarterly business review calls to be on the same page.

Denials

We believe that starting with “denials” is the basis of understanding what’s right or wrong with your billing processes. Therefore, we always start by working with your current denials, making process recommendations based on our expertise, making adjustments all the way up to provider credentialing and therefore lay a solid groundwork to take your revenue cycle management processes to the next maturity level.

Depending on the buckets we are working on – whether they are denied, underpaid, pending / no responses etc, our team will call patients, payers, 3rd party facilities as needed to ensure we maintain the latest status of why and where the claim is “stuck”. After that, we ensure that our team takes the next corrective step to ensure that the current claim is paid for. In addition to that, we ensure that the learnings from this claim are sent to the upstream teams / processes to ensure non-recurrence of the same.

Revenue cycle management is a cycle where each team feeds off the other and each team has to work tightly, hand in hand to take care of the patient account holistically.

We understand that very well and our people, processes and technologies are built to facilitate that kind of team collaboration

Patient collections

First and foremost, we employ technology to achieve a bulk of the work. Our IT team has developed patient bill pay solution for us (which you are free to use as well) that we use in conjunction with our patient contact center solution.

This allows us to identify all patient balances in real time. Using our solution, we send out automated balance reminders to patients. In our communications we also make it super easy for patients to just click on a link and pay via check or credit cards.

Our patient contact center team constantly monitors aged accounts, patient responses and works closely with our payment posting team to ensure that patients’ payments are posted within 24 hours.

As we all know, sometimes, patients simply do not pay regardless of how many statement balances or reminders we send them. In these cases, our team evaluates whether the balance is high enough (e.g. > $50) to call and collect or not. This decision is made in conjunction with your practice and is assisted by looking at the life time value of a patient as well.

These decisions cannot and should not be made in silos or a vacuum. You need to balance the overall life time value of a patient and make a decision on whether further attempts should be made to collect from this patient or not.

Our team reviews and corrects patient’s demographics as needed, helps patients get their balance statements, answers all patient questions in details and assists the patient with payment plans as needed.

Our team calls as first party collectors (on your behalf). As we all know, calling on patients to collect balances is a very tough balancing act. We go above and beyond to make patients happy with the outcomes so that they pay their balances and at the same time, the relationship is still maintained for future visits.