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Medical Billing
Flash Demo
Medical Billing Workflow :                                                    
Credentialing
Scheduling
Eligibility Verification
Pre authorization
Coding
Charge entry
Payment Posting
AR follow-up
 
Medical Billing Workflow :
The following outline would give in brief the workflow process from the time a patient is seen by a physician.
Credentialing

Credentialing a physician, who move from one state to another, want to start the practice thereby performing the process of setting up contract negotiation on behalf of doctors with the insurance there by achieving the best possible rates for the practice.
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Scheduling

Scheduling appointments for patient, by giving suitable time slots for patient to meet doctor and make sure that doctor on a regular time interval meet the patient to maximize their productivity and increase their cash flow.
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Eligibility Verification

Eligibility Verification determines the following details while we call the insurance

Check for Patient's Effective & Termination date
Check for Patient's Annual individual in Network Deductible
Check how much the patient's has met towards Deductible Amount
Check for "Outpatient PCP OFFICE VISIT COPAY"
Check if there is any Pre-Existing waiting period for patient's Policy
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Pre authorization

Pre Authorization for specialist service will be determined by the insurance company, which will ensure that the service is not denied by the insurance or if we get the auth, we are going to get the payment for sure, thereby accounts getting denied for auth is neglected.
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Coding

Demographic Entry: the doctor sees the patient. Demographics, super bills/charge sheets, insurance verification data and a copy of the insurance card i.e. all the information pertaining to the patient is sent to the Billing office.
Client office scans the source documents and saves the image file to an FTP site or on to their server under pre-determined directory paths.

Scanning/Segregation person retrieves the files and prints them and ties up with the control log for number of files and pages.
Illegible /missing documents are identified and a mail is sent to the Billing office for rescanning.
Documents are batched, numbered and sent to the appropriate departments for action.
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Charge entry

The Charge Entry personal creates a charge, according to the billing rules pertaining to the specific carriers and locations .All charges are accomplished within the agreed turnaround time with the client.
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Payment Posting

Audit:
Charges are checked for accuracy and again verified by audit department for accuracy and compliance with rules.
Claims are filed and information sent to the Transmission department.

Transmission Department prepares a list of claims that go out on paper and through the electronic media. Once claims are transmitted electronically, confirmation reports are obtained and filed after verification. Paper claims are printed and attachments done, if necessary, stuffed into envelopes and sent to the US for postage and mailing.
Transmission Rejections are analyzed and appropriate corrective action is taken.
Cash Application team receives the cash files and the deposit control log is prepared. This helps to reconcile the deposits at the end of each month. During cash application overpayments are immediately identified and necessary refund requests are generated for obtaining approvals. Also underpayments/denials are highlighted for further research by the denied claims team.
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AR follow-up

Accounts Receivable and Claim Follow up

Once claims are sent to insurance, if we are yet to receive the EOB’s from the insurance, accounts receivable team will call insurance and get the necessary details like paid, pending or denied status, and also will help to resolve the claims and also the cash flow for the doctors. Process involve in AR follow up are • Pre call analysis
 • Call insurance
 • Post call documentation
 • Reporting Payment Posting and Reconciliation

Internal Audit and Quality Check
Our medical billing team follows strict quality control Standards. The quality assurance team reviews all claims before submission. A billing and coding claims reviews log is maintained. A monthly billing review conducted.
We conduct detailed procedural processes to assess quality at every stage.

Shadow Processing - We audit every single file/transaction for accuracy and errors.
Random Auditing - In addition to Shadow Processing, our experienced quality managers conduct random auditing tests to ensure quality at all levels.
Communication
Internet, Email and voice are the means of communication with clients. Templates and protocols have been developed to streamline the everyday communications process. Both companies do a review of the update spreadsheets and the fields relevant each.
All electronic documents are preserved for about 120 days unless other wise specified (with all paper documents being destroyed)

Security
With this billing system, confidentiality is maintained throughout. Employees are only given permission to access required files and folders, thus maintaining the confidentiality of clients and patient data.
Another important feature of ACS is to have the capacity to replicate your processors and procedures. This means that you do not have to change anything in the office.
ACS follows a systematic process of backing up all the data which is received from your office as well as all the internal data and communication.
There are programs designed to communicate reportable complains items to billing agents, and to ascertain that all staff know and understand the US medical billing industry and all its complexities.
A US management team is responsible for interfacing the Indians site’s program with each contracted medical billing entity in the US. Ongoing program development and implementation significantly reduce the risk of improper conduct As a part of our quality driven process, we have a Self audit process, followed by a Quality check, done by a well qualified and experience Audit person.
As all our client appreciate our Internal auditing making sure that errors are identified where it arises there by reducing the risk of claim with error reaching the insurance.
Also Audit personals are periodically updated by conducting various seminars and participating in Audit workshop, which updates there skills and make them aware of various changes taking place in Quality check.

Daily Reports and Pending Reports
Reports are maintained on a Daily, Weekly and Monthly basic for Coding. Charge Entry and Payment Posting. Also reports can be altered to client’s need by using our billing software, thereby keeping the client updated on day to day happening and raising queries for any pending claims requiring client’s clarification, for it to be transmitted to the insurance company.
We regularly sent daily status reports highlighting the number of files in processing and reasons for delays. We also sent consolidated monthly reports. The following are a few of the reports:
 • Daily reports for payment posting and denials
 • Daily revenue status reports for payments
 • Daily feedback implementation report

Monthly Billing Review
Every month, we hold billing review meetings where the entire team involved in billing processes is present. Every person involved in data entry, billing and payment posting, coding and documentation, denials review and down coding participates in the monthly review which includes.
An analysis of trends from the claims review log an update of any recent changes in billing or coding practices, from recent newsletters of insurance carriers current practice issues regarding the billing function
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Staff Education/Training
Awareness programs for all employees’ ongoing training and testing programs link HIPAA education to staff rewards HIPAA resource directory to update employees on regulations, news and events
Transaction Standards
Dedicated team of software programmers developing HIPAA compliant transaction there is a thorough understanding of patient confidentiality and all medical records. It is also well known that HIPAA makes constant changes as it incorporates or discards certain practices. Indian companies make sure that they are always aware of such changes, thereby ensuring that all information is safe and adheres to the highest standards of quality.
HIPAA compliance
Trained in regulations related to Medicare, Medicaid, managed care, third party liability, workers compensation, Preferred Provider organizations, indemnity insurers Proficient in CPT, HCPCS, ICD-9 coding Level I, II, III HIPAA covers all protected healthcare information. It does not apply to specific records, but to information. This material is protected in any form by HIPAA and it continues to apply whether the content is being printed, discussed orally, or changes in form. For organizations that deal with the electronic management of healthcare information it is not only vital to protect the electronic maintenance and transmission of this data, but also protect any paper versions or oral discussions pertaining to this information.
The Challenge
ACS was initially approached by the company to take care of their patient demographics and charge entry functions. Since the client was a first-time outsourcer, the first main concern centered on quality. The client's existing billing team had an error rate of 4%. Our team had to work within an error rate of 2%, despite having minimal training. This was a huge challenge, since the team had to be trained on the software and the methodology used by the onshore team. ACS also had to make sure that the transition from onshore to offshore be smooth and painless, with the least amount of change and much higher productivity.
The Solution
We started with one full time employee to take care of patient demographics and charge entry for about 7-8 files per month. Within the second month, we were processing 150 files with error rates that were below 2%. To ensure a smooth transition of operations from onshore to offshore, we made sure that we replicated the entire existing onshore process without any alterations. To ensure that quality was not compromised, a quality assurance team with more than 3 years of experience in Payment Posting audited all the processed files and charge sheets.
Testimony
ACS handled the complete medical billing process for a large medical billing company based in the US, improving productivity by 40% with error rates below 2%. The client was so satisfied with the results that he decided to outsource the rest of his medical billing processes to us, which included Patient Demographics, Charge Entry, Payment Posting, Insurance Calling and Patient Calling functions. We are now handling all the medical billing functions of the client. and our error rates are less than 2%.
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