Eligibility & Benefits
- Access detailed data directly within your electronic health record system.
- Confirm if services are covered based on specific CPT codes.
- Identify if prior authorization is necessary for certain procedures.
- Ensure patients receive the maximum benefits available under their plans.
- Clarify what patients are accountable for regarding deductibles, copays, and coinsurance.
- We align with your protocols for checking eligibility and benefit details for patients.
- Equip your team with the knowledge to collect necessary payments at the time of service.
- Enhance your practice's collection rates by improving patient understanding and preparation.
Prior Authorization
- Streamlined Prior Authorization Process: Simplifies the approval workflow to reduce administrative burden on healthcare providers.
- Insurance Verification: Confirms patient coverage and policy details before submitting prior auth requests.
- Real-Time Status Tracking: Provides up-to-date tracking on the progress of each authorization request.
- Appeals and Denial Management: Assists in managing denied authorizations and submitting appeals to insurers.
- Compliance and Documentation Support: Ensures all necessary clinical documentation is gathered and submitted according to payer requirements.
- Reporting and Analytics: Delivers insights into authorization trends, approval rates, and process efficiency.
Charge Entry and Claim Management
- Accurate Data Entry of Patient Demographics and Insurance Details
- Timely Entry of Charges Based on Provider Documentation
- Validation of CPT, ICD-10, and Modifiers for Coding Accuracy
- Real-Time Claim Scrubbing for Error-Free Submissions
- Automated Claim Generation and Batching
- Electronic and Paper Claim Submission
- Tracking Claim Status and Rejections
- Rapid Resolution of Claim Rejections and Edits
- Coordination with Providers for Missing or Incomplete Information
- Insurance-Specific Rule Application to Prevent Denials
- Ongoing Quality Checks to Minimize Rework
- Regular Reporting on Charge Lag and Claims Performance
Claim Submission
- Timely Submission of Clean Claims to Insurance Payers
- Electronic and Manual Claim Submission Support
- Integration with Clearinghouses for Seamless Delivery
- Verification of Payer-Specific Billing Requirements
- Claims Prioritized Based on Payer Guidelines and Deadlines
- Real-Time Monitoring of Submission Status
- Immediate Rectification and Resubmission of Rejected Claims
- Batch Processing for High-Volume Submissions
- Audit Trail for Every Submitted Claim
- Automated Alerts for Submission Failures
- Submission Reporting by Provider, Payer, and Specialty
- Adherence to HIPAA and Compliance Standards
Payment Posting
- Accurate Posting of Insurance and Patient Payments
- Electronic Remittance Advice (ERA) and Manual EOB Processing
- Real-Time Payment Reconciliation
- Identification and Posting of Co-pays, Deductibles, and Co-insurance
- Denial and Partial Payment Flagging During Posting
- Prompt Adjustment and Write-Off Management
- Secondary Insurance Billing Triggered by Payment Posting
- Patient Account Balancing and Overpayment Tracking
- Daily Deposit Reconciliation with Bank Statements
- Detailed Payment Audit Trail for Transparency
- Custom Reports on Payment Trends and Payer Performance
- Compliance with HIPAA and Financial Integrity Standards
Accounts Receivable and Follow-Up Management
- Daily Monitoring of Outstanding Claims and Aging Buckets
- Proactive Insurance Follow-Ups via Calls, Portals, and Emails
- Prioritized Follow-Up Based on Claim Aging and Value
- Identification and Resolution of Denied or Delayed Claims
- Re-submission or Appeal of Denied Claims as Needed
- Root Cause Analysis to Prevent Repeated Denials
- Dedicated AR Specialists Assigned to Each Client
- Tracking of Payer-Specific Timely Filing Limits
- Escalation Protocols for Stalled or Unresponsive Payers
- Regular Reporting on AR Days, Recovery Rates, and Trends
- Patient Follow-Up for Unpaid Balances with Sensitivity and Compliance
- Improved Cash Flow Through Focused Recovery Efforts
Denial Prevention
- Pre-Submission Claim Scrubbing for Coding and Data Accuracy
- Verification of Patient Eligibility and Benefits Prior to Service
- Real-Time Edits to Catch Missing or Invalid Information
- Implementation of Payer-Specific Rules and Billing Guidelines
- Pre-Authorization and Referral Management to Prevent Coverage Issues
- Clinical Documentation Review to Support Medical Necessity
- Regular Coding Audits and Compliance Checks
- Automated Alerts for Common Denial Triggers
- Root Cause Tracking and Prevention of Repeat Denials
- Staff Training on Front-End Best Practices and Documentation Standards
- Feedback Loops Between Billing and Clinical Teams
- Denial Trend Analysis for Strategic Improvements
Denial Appeals and Management
- Systematic Review of All Denied and Underpaid Claims
- Classification of Denials by Type, Payer, and Root Cause
- Timely Initiation of Appeals Within Payer Deadlines
- Preparation of Detailed Appeal Letters with Supporting Documentation
- Strong Medical Necessity Justification and Coding Clarification
- Resubmission of Corrected Claims When Appropriate
- Coordination with Providers for Additional Documentation or Clarifications
- Follow-Up on Appeals to Ensure Resolution and Reimbursement
- Escalation of Unresolved Cases to Payer Supervisors or External Review
- Denial Analytics to Uncover Patterns and Inform Preventive Measures
- Ongoing Communication with Payers to Understand Policy Changes
- Reporting on Appeal Outcomes and Recovery Rates
24/7 Monitoring
Proactive Cybersecurity Measures
Risk Management
Incident Response Planning