Contracting and credentialing

From setting up contracts to submitting application forms to insurances, our dedicated team will help you get credentialed with insurances. We identify top carriers based on location and the type of services you provide and initiate credentialing process on your behalf. This ensures predictability and profitability from day one.

Global contracts with TPAs

We coordinate and negotiate with Third Party Administrators on setting global contracts for services provided. Establishing global contracts result in better reimbursement rates and provide consistency with payment patterns.

State-wise compliance

Reporting service quality data to state health registries is a measure for centers to demonstrate credibility and it is a mandate in some states. For example, in New York state, it is obligatory for outpatient surgery centers to submit quality data to SPARCS and HCRA reporting systems. We have automated process for gathering, consolidating and submitting data in SPARCS compliant format for centers and we help ASCs to report the HCRA component to NY state. We can work with your center to understand your state’s quality requirements and do it on your behalf, so you can focus on your patients.

CAQH Database maintenance

Physicians have to update and re-attest their CAQH profile every three months. We consult, send reminders and maintain the database on your behalf whenever required.

Audits

We work with centers towards developing quality protocols and undertake internal audits. If your center is audited, we can help you through the audit process and meeting regulatory requirements. If you want to identify process gaps, we can conduct quality drills to help you get a complete picture of your business.

In network/out of network patient eligibility and benefits verification

Major carriers (including some of those in Insurance Exchanges), patients are not entitled for out of network benefits. This translates to loss of revenues even after rendering quality services. We avert this problem by proactively pursuing benefits verification for all the patients. As a process, we complete patient benefits verification for all scheduled patients two days prior to the date of service. Some information we gather include, type of plan, coordination of benefits, copays and deductible, covered services and out-of-pocket information.

Procedure pre-authorizations

We understand that the time and resources invested in persuading an insurance company to cover a medication or procedure is an expensive and annoying process. It often causes distraction from providing quality care for your patients. We undertake the task in-house for you. We complete procedure authorizations for all patients and report the authorization details to you five days prior to the date of service.

Patient financial responsibility verification

We help you control your patient receivables by generating and sharing patient liability reports regularly. This process helps us track and study outstanding balances and helps your center push for pending balances from the patients at the time of next appointment. This practice controls the patient owed amount and keep the accounts clean.

Timely claims submission

We benchmark ourselves at submitting claims within 48 hours from the date of service. This accounts for a consistent revenue cycle and a regular cash flow. We do this by using intelligent scripts that automatically extract CPTs and ICDs from super bills, check coding compliance, modifier usage and enter them into a Practice Management System. The otherwise monotonous task of manually entering charges is replaced by automations while ensuring greater efficiency. This saves us time and resources to do more.

Focus on quality

We have crunched our expertise and knowledge into executable actions in the maximum possible areas of the revenue cycle management. This includes charge entries, eligibility verifications, online claim status and quality checks. Prior to submitting claims to carriers the claims are scrubbed across a proprietary rules engine to verify accuracy and flag inconsistencies – this is the first tier of quality analysis. After scrubbing, the claims are again verified manually line by line – this is the second tier of quality analysis and it helps us achieve a first pass ratio of greater than 95% upon first submission.

Daily denial management

It is crucial for centers to keep a track of denials. We follow daily denial management process to ensure claims reconciliation as quickly as possible. Our teams are cohesively tied together. Whenever a denial is encountered, it is flagged and instantly sent to the accounts receivables team for resolution. Both the teams are in constant coordination with each other until proper denial resolution is achieved. This avoids accumulation of accounts receivable, reduces A/R days and increases collections.

Regular insurance follow-ups

With each additional day from the date of service, it becomes more difficult to get reimbursed. As crucial as it may sound, some centers typically decide on day/s of the week to work on denials. By this time some claims already enter the 60 or 90 day buckets and it gets tough to recover the balances. Depending on insurance, we follow up on claims as early as the fifteenth day from the date of service. This enables us to get accurate status on claims and gives us a head-start in resolving those denied and predict revenues for the practice.

Technology infrastructure - ERA/EFT

Receive payments quickly and electronically by directly connecting with insurances. We constantly work and coordinate with clearing houses and carriers to set up Electronic Remittance Advice (ERA) and Electronic Fund Transfer (EFT) utilities with all possible carriers. Setting this infrastructure ensures quick payment reconciliation and accurate revenue projection.

Payment posting and reconciliation

Our team checks payment gateways everyday and reconcile electronic payments as soon as they are received and balances are matched on the same day. Manual payments are posted in batches as and when received. Pending patient balances are applied and adjusted regularly to avoid accumulation of unapplied payments. Apart for these, we also update and assist centers on payment recoupment and reversals.

Outstanding balance reports

To ensure noting is left on the table, we regularly generate an outstanding patient balance report to identify precise patient balances and delinquent accounts. We share this report with you and determine a course of action to recover balances. We provide suggestions on payment plans, discounts and recovery methods to best collect pending balances.

Daily patient statements

We work together with your center to device a process for generating and sending balance statements to patients immediately after patient balance is determined or after insurance portion is settled. This increases the chances of payments from patients.

Paid to patient collections

There are scenarios where insurances process payments directly into patient accounts. In such cases, we coordinate with your center to outline a action plan. A typical action plan may look similar to this: A letter explaining the date, time and type of service rendered; followed by regular phone follow ups.

Collection coordination

For delinquent accounts we collaborate with the center and coordinate with collection agencies in our partner network for recovering overdue patient balances.

Regular follow ups

Patient receivables is a major roadblock with most centers and groups. We aggressively pursue outstanding balances. Our follow up process is a blend of regular statements, phone calls and send-to-collections warning letters.