Provider credentialing is the process of getting a physician or a provider affiliated with the payers. It is critical step in Revenue Cycle Management which involves a lot of manual work in terms of completing the application forms, providing clarifications to questions from the payers and following up to complete the credentialing. ABCLLC focus on getting the provider enrolled quickly to eliminate any delays in payment. Our goal is to simplify the process and reduce the cost. Our team will manage the credentialing process from the start to end of the applications.
- NPI registration (Type I and Type II)
- Medicare (PECOS) and Medicaid credentialing
- Managed care credentialing (Medicare and Medicaid)
- Commercial insurance credentialing
- Follow up with the insurance payers until the final credentialing approval
- Re-credentialing with all the payers
- CAQH profile creation, maintenance, and re-attestation.
- Hospital PHO/IPA applications.
- Payer fee contract negotiation.
- Medical license and DEA renewals.
CAQH stands for “Council for Affordable Quality Healthcare”. It is an online database that stores provider information. Providers grant access to their information to insurance companies rather than sending information to each insurance company seperatly. Most of the Health Insurance Companies use CAQH and it is a prerequisite for their enrollment process.
CAQH Credentialing process:
- Creating the new CAQH ID and and maintain the database
- Complete the application and send in requested documents
- CAQH profile re-attestation for every three months
- Grant insurance companies access to online application
- Reminders to providers about expiring certificates to re-apply
Provider demo maintenance
Maintaining the practice or provider demographics with the payers is very important when the providers are re-locating, adding satellite locations, specialties, changing the practice phone and fax numbers etc. ABCLLC team will help the transitions without any interruption in service and monthly revenue.
Fee schedule analysis and auditing
ABCLLC will compare the payer contracted fee schedule and actual fee paid every month and detailed monthly audit reports are Emailed. Difference in the payments are checked and reclaimed with interest to the payers.
ERA/EFT services –Getting paid electronically
ABCLLC will setup the EFT payments for the providers in which payer payments deposited directly in the bank which save lots of manual hours to the practice. ABCLLC will also help you to switch the paper EOBs into electronic ERAs.
Certified medical coders ensure that each claim has high specificity ICD-10 coding. High specificity ICD-10 helps the claims to get paid in first submission and reduce denials. The diagnosis and procedure codes are taken from medical record documentation, physician’s notes, laboratory and radiologic results, etc.
ABC coders ensure the codes are applied correctly during the medical billing process, which includes abstracting the information from documentation, assigning the appropriate codes, and creating a claim to be paid by insurance carriers. ABC coders translate the documentation into standardized codes that tell payers Patient’s diagnosis, Medical necessity for treatments, services, or supplies the patient received, Treatments, services, and supplies provided to the patient and any unusual circumstances or medical condition that affected those treatments and services
Charge entry plays a crucial role in Revenue Cycle Management. Charge entry is a process of creating a claim for a service rendered by the provider to the patient. A claim is the most important aspect for getting reimbursements. Even a minor mistake in charge entry impacts the entire outcome. We give high importance for accurate charge entry in order to submit clean claims.
Our goal is to get paid at the very first submission and the team relentlessly pushes harder to achieve higher first–pass rate of claims. We are experienced in various Practice Management Systems and various medical specialties. We have predefined rules in charge entry for different medical specialties, which reduces the room for errors and contributes to clean claims.
Charges entry includes the following
- Charge/Superbill files
- Patient demographics entry/verification
- Eligibility verification
- Claims creation
- Reminder for missing charges
Charge file downloads
ABCLLC will download the charge files from Dropbox, Google Drive, PMS, FTP, Email, Fax etc. If the client did not have the setup, we will train them to upload the files in PMS.
Patient demo entry, data and eligibility verification
- All new patients information such as patient, guarantor, Insurance information etc are captured.
- All existing patients information are verified and updated if there is any change.
- All non-office patients, demographics verified by logging into hospital portal/requesting through fax.
- ABCLLC verifies insurance ID number, name/address of the insurance, group name/ number, effective/termination date, the name of the insured, date of birth and the relationship of the insured to the patient.
- ABCLLC verifies coverage for primary / secondary / tertiary payers by utilizing payer websites, automated voice response systems, or by calling payers.
- All self-pay/indigent patients are checked for Medicaid and other possible insurance eligibility.
All the claims were created within 8 hours of the charge/superbill files received..
- Charges are entered in PMS based on speciality specific rules.
- Handwritten diagnosis and procedures are analyzed to find the appropriate ICD-10 and CPTs.
- Handwritten hospital patients diagnosis are cross checked with the patients progress notes by logging into hospital portal for accuracy.
- Using appropriate modifiers, mapping, linking codes etc., to avoid denials.
- Educating providers if any obsolete or deleted CPT’s handwritten in charge sheet/superbills.
- Precertification number for non-office patients are requested through fax or by calling the facility before the claim is created.
- Email request to the clients regarding missing Diagnosis, CPTs, DOS, etc,.
Missing charges reminder
It is very important to submit claims to the insurance within the filing time limit period. Delay in the charge entry directly impacts the reimbursements.
- Weekly reminders to provider regarding missing charges.
- Weekly reminders to providers on incomplete office progress notes.
All charges are audited and checked by the Quality control team. Checking team collects data on common errors and fix systemic problems that affects payment delays and bad debt. This long term perspective improves the collection rate and help to protect future cash flows by fixing problems that affect the patient-provider relationship. ABCLLC service is unique because we strive to eliminate problems before they happen. All claims are reviewed for errors and risk of denial before claim submission.
Maintain a review log for billing claims
The most common reasons for claims rejections are logged and the accumulated logs helps us to track rejection trends on remittance advice. We monitor and evaluate these trends in order to resolve the problems that are causing the denials and rejections for your practice. This way, you get increased revenue through reimbursements and reduce the risk of future claims rejections.
Eligibility, Referral and Pre-cert Verification
- All patient’s insurance coverage are verified for primary and secondary payers
- All verification are done by calling the payer or online portal
- All referral required patients are identified way before the appointment and alert is created in PMS to along the front office on the appointment day
- Weekly Email reminders sent for referral missing claims
- Missing precertification numbers are obtained by calling, faxing, Emailing and through hospital/facility/insurance portals
- Missing precertification claims are followed up every week
- Weekly Email reminders sent for prior authorization missing claims
Electronic Claims Submission
ABCLLC submits all claims electronically within eight hours from the encounters or charge files received. Electronic claim speeds up claim processing times. It provides a confirmation that the claims have reached the payer on time. Electronic claims reduce rejections and denials drastically. ABCLLC can work with different kinds of clearing house. Many payers have very strict claim filing time limits. Electronic claim filing helps to stay on time and enhance cash flow. Before the claims are submitted the following checks are made
- Appropriate modifiers are added to the CPTs
- High specificity diagnosis are added by cross checking the progress note
- Reminders sent to providers before claim submission if the claims are created without the completion of progress note
Clearinghouse Rejections and Batch Checking
Clearinghouse generates payer acknowledgement and rejection report for every claim batch submitted. These reports are analyzed line by line and erroneous claims are fixed and resubmitted. These reports help us to improve operational efficiency. Electronic claims submitted are commonly scrubbed for payer, specialty and coding rules. ABCLLC work on rejected claims immediately and resubmit them with required corrections. After submitting the claims electronically batches are checked in clearinghouse portal to confirm if the claims are accepted by the payer and clearinghouse.
Medical records request and submission
- Medical records requested by payer or downloaded directly from the hospital portal rather than relaying on the practice
- Medical records request are submitted directly through insurance portal
- All worker compensation claims are submitted with medical records in first submission
- Separate invoice is created for attorney offices requesting medical records. Medical records are sent after the payment received from the attorney offices
- Weekly reminder sent to the provider to complete unsigned medical records
Accuracy in payment posting is imperative for an optimized revenue cycle. Once payments are posted to patient accounts each denials are addressed separately. Rejected claims, late payments and untimely patient statement submission can eventually lead to huge losses for a healthcare practice. ABC LLC handle the payment posting according to client-specific rules that would indicate the cut-off levels to take adjustments, write-offs, refund rules etc.
ERA and paper EOB posting
Electronic remittances typically contain a high volume of payment transactions. The processing of ERA batches involves loading the files into the revenue cycle system, processing exceptions from the batch run by making corrections using the functionality available on the revenue cycle system. Payment data from scanned images of Explanation of Benefit (EOB) document are captured line by line and posted to the respective patient accounts. We develop practice/physician specific business rules to ensure accurate payments, adjustments, write-offs and balance transfers are posted correctly.
- All ERAs are posted on the same day.
- Sequestration and MIPS penalty are posted in separate adjustment code.
- 835 files are directly downloaded from Payspan, PNC, Zelis, Echo, Redcard, JP Morgan, Optum etc into PMS for small insurances such as USAA, Aetna continental etc.
- All EOBs are posted within 8 hours
- Paper checks cashing details are verified with providers and Insurances.
- Downloading paper EOB files through Dropbox, PMS, FTP, Fax, Email etc.
- Practice employees are trained to upload paper EOBs and Medical records in PMS
- ABC LLC does electronic payment posting in to the medical billing software and handles the exceptions (fallouts) manually to make sure no payment is missed. Missing ERA’s from clearing house are traced every week by calling them.
- ABC certified coders analyze the Medical records for claims which are down coded due to lack of documentation and suggest appropriate codes to the providers.
- Continuous monitoring of payee address in ERA’s/EOBs.
- Uncashed checks or checks sent to incorrect address are rectified.
- Every year charge fee schedules are updated depending upon the changes in Medicare, Medicaid, Commercial and Self-pay fee schedule to reduce contractual adjustments.
- Every week missing paper EOB reminders sent to the providers
- Refund letters are analyzed and emailed to the provider to send the check to the payer on time
- Educating the providers frequently regarding obsolete ICD, CPTs, Insurance reimbursement policies etc
- Payments received in the bank are reconciled every month.
- Weekly charges and payments report are texted to the providers
- Monthly payment reports Emailed to the providers
- Year-end reports Emailed to the practice to understand the practice production, collection and outstanding account receivable.
- Payer paid amount is compared with ACO’s fee schedule to make sure the provider is paid according to the ACO/payer contract.
- Adjustments and denials are adjudicated properly which helps patients understand their responsibility.
Denial management is a vital component of revenue cycle management in medical billing process. Denial Management is to investigate every unpaid claim and appeal the rejected claims appropriately. It demands extensive knowledge and timely execution. ABCLLC have a well-experienced team of denial professional trained to identify the root cause of expensive denials. Our dedicated and skilled denial professionals can handle denial efficiently and in a timely manner to minimize denials reimbursements. ABCLLC correct and resubmit the claims and file an appeal towards deemed medically not necessary claims. The appeal letter is sent to retreat the payer for their mistakes and make them clarify why the original processing of the claim was incorrect. Systematic tracking of denials will collect data back to the billing process to prevent future denials of the same nature, thus ensuring first submission acceptance and payment of claims. Denial Management team helps you to take control of your denials and accelerate reimbursements.
Denials occur because of
- Inaccurate or Incomplete Insurance information
- Absence of Pre-Authorization number
- Filing claims after the allowed time frame
- Credentialing and non-enrollment errors of the provider
- Medically necessity of patient
What we do:
- Examining the volume of denials and analyse
- Reckon denials not meeting the deadlines and claim age
- Statistically estimating denials based on payers, CPT codes and ICD 10 standards/HIPAA regulations
- Grouping the denials by coding and CPT/HCPCS
- Preparation of a comprehensive denial management report
- Systematic approach of tracking and managing claims denials.
- ABCLLC will reduce denial backlogs and apply best practices to reduce denials overtime
- We work with payers to discuss, revise or eliminate contract requirements that lead to denials and appeal
- Prevent future claims denial by reconciling missing patient information with existing records
- Denied claims are appealed to reverse the payer decision such as fee schedule, no pre-authorization & pre-cert (extenuating circumstances), filing time limit, Medically necessity denial, etc
- Focus on appealing claims that bring the highest amount of revenue than the provider adjustment.
- Claims-related Alerts activation to inform particular denials.
- Creating awareness to the client by sharing unpaid denial issues.
Any payments due from payers, or other guarantors are considered account receivable. It is crucial for physician practices to track the claims they submit to insurance companies to optimize revenue recovery and increase revenue. The goal of accounts receivable management is to achieve the shortest collection period possible.
ABCLLC follow up the claims in 30 working days from the claim submission date
- Claims never go missing
- Minimize time for outstanding accounts
- Shrink account receivables by 45 – 60 days
- Claim denials can be followed up
- Helps in recovering overdue payments
- Recovering claims kept pending for information
AR Follow-up and analysis process
- Accounts receivable team regularly follows-up with the insurance company to know the claim status on 30th day from claim submitted date.
- Claim inquiries are done efficiently by live chat, secure email,Insurance calling and secure message on insurance portal.
- Claims needed resubmission are checked for all necessary documents such as Medical records, Referral, Prior Authorization etc.
- Unpaid VA claims are followed up by submitting medical records and resubmission every 45 days.
- ABCLLC conducts frequent AR analysis to compile all claim details to initiate corrective actions for non-payments.
- Insurance claims pending because of COB, Pre-existing condition etc are followed up aggressively, every week.
- Every week Account receivable aging reports are compared with previous weeks to identify:
- Unpaid Claims
- Low Paid Claims
- Denied Claims
- Rejected Claims
- Claims not on file
The following default reports are generated monthly.
- Account Receivable Aging Report by Primary Insurance
- Account Receivable Aging Report by Secondary Insurance
- Account Receivable Aging Report by Patient
- Collection report
- Charges and payments comparison
- Denial summary
- Total visit comparison
- Coding analysis
- CPT units production comparison
- Encounters comparison by service location
- Payor mix summary
- Most of the patient balance past due need a simple reminder to collect the balance.
- Almost 56% of patients delay paying their Medical Bills. ABCLLC calls each patient to remind about the balance and collect it
- The more communication with the patients, the more collection
- ABCLLC finds the correct address for all patient statements which are “return to sender” and resent the statement
- ABCLLC check retroactive insurance every month for uninsured/self-pay patients to check if the patient got Medicaid or any other insurances to cover the service
- ABCLLC send patient statements immediately after posting insurance payments and handles inbound patient calls clarifying billing questions
- ABCLLC engages patients in digital channels by sending eBills which helps the practice to receive the payments much faster.
- ABCLLC accepts payments from patients by web, phone, paper checks, etc
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