We verify eligibility with the patient’s insurance provider to confirm their qualification for a service. This verification process and obtaining prior authorization are essential as they provide a clear understanding of insurance coverage and the patient’s financial responsibility. Consequently, this helps providers submit clean claims, minimize denials, reduce write-offs, and enhance collections.

Our services for eligibility verification and prior authorization encompass:

• Confirming coverage with all primary and secondary payers
• Assessing prior authorization requirements
• Initiating pre-authorization requests on behalf of the provider and explaining medical necessity
• Following up on pre-authorization requests
• Notifying the healthcare provider of approval or denial before the patient’s appointment.

Entering patient demographics is a crucial step in initiating an insurance claim. Inaccurate demographic details are a primary cause of claim denials. Likewise, precise charge capture minimizes revenue losses.

Our services for patient demographics and charge entry comprise:

• Recording demographic information such as patient, guarantor, and insurance details
• Documenting service date and location, billing provider information, referring provider, admission date, prior authorization number, CPT/procedure codes, diagnosis code, modifiers, and unit count
• Conducting charge audits

Medical coding plays a pivotal role in the revenue cycle process. Ensuring accurate coding of rendered services, including the correct utilization of CPT, HCPCS, ICD codes, and modifiers, is imperative. Leveraging the extensive expertise of our medical coders, we proficiently and precisely code services in adherence to guidelines. We take pride in our dedicated audit team specializing in comprehensive reviews of the coded services.

Our medical coding services encompass:

• Facility and professional coding
• Adherence to current CPT, HCPCS, ICD code sets, and modifiers
• Validation of DRGs
• Management of coding denials
• Conducting coding audits
• Risk adjustment coding
• Quality checks before charge entry

We meticulously review each Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) from insurance companies and make necessary adjustments. Our team accurately posts payments, co-insurance, deductibles, and insurance adjustments. Furthermore, we handle secondary claims submissions and patient statements. Denials are promptly directed to the denial management team for further action.

Our payment posting services comprise:

• Electronic payment posting
• Manual payment posting
• Posting of patient payments
• Posting of denials
• Posting of refunds

Following up on accounts receivable (A/R) is essential post-claim submission. It identifies the adjudication status of the submitted claim and facilitates understanding of the claim outcome. Timely notification of a denial aids in rectifying the claim in its early stages, preventing it from becoming ‘untimely’ for appeals or corrections.

Our services for accounts receivable management encompass:

• Persistent follow-up across all payers on all outstanding A/R
• Cleanup projects for inherited A/R
• Management of underpayments
• Handling of denials
• Prompt preparation of appeals
• Resolution of A/R and development of strategies through comprehensive analysis

This represents a crucial aspect of the revenue cycle process. A significant portion of revenue is held up here due to denied claims, demanding extra focus. We maintain a specialized team for denial management, well-versed in recognizing various denial types and implementing corrective measures. We provide regular reports to providers, identifying common denial patterns and offering strategies to prevent them in future submissions.

Our services for denial management comprise:

• Scrutinizing EOBs/ERAs to pinpoint denials
• Liaising with insurance companies to obtain additional information
• Drafting appeals, rectifying claim details, and resubmitting accurate claims

Proper management of credit balances is crucial to avoid potential compliance issues. Credit balances arise from overpayments from insurance companies or excess payments by patients. Therefore, resolving credit balances promptly is essential for maintaining compliance, ensuring clean accounts receivable, and enhancing patient satisfaction.

Our services for credit balance resolution encompass:

• Identification and analysis of credit balances
• Timely correction of errors
• Issuance of patient/insurance refund letters