Medical Billing

Medical Billing Workflow
The medical billing process at Proskribe Services involves these simplified processes. For the intent of explanation, the functioning on one whole unit that takes place in Medical Billing. Here is how it happens...

The Doctor's Office
A patient visits a doctor and explains the problem. The doctor diagnose and draws out a chart about the treatment to be rendered, for example if a patient named John Doe has stomach ache then a sequence chart would be drawn up by the provider to explain the treatment pattern.

Documentation at the Front Desk
The patient hands over a copy of his insurance card; let us assume that the carrier is Humana Gold Plus. With the copy of the card the office manager needs to verify if a referral or pre-authorization needs to be obtained and then contact the respective Primary care physician (gatekeeper) and get that documentation in place.

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 or to our office.

The Billing office scans the source documents and saves the image file to an Secure FTP site or on to their server under pre-determined directory paths.

Our Scanning department retrieves the files. We have developed in-house software called BISSY (BILLING INTEGRATED SUPPORTING SOFTWARE). Using this software, the scanning team splits the images from a file and arranges them according to patient names.

Files are then sent to the appropriate departments with the control log for the number of files and pages received. Illegible/missing documents are identified and a mail is sent to the Billing office for rescanning.

Pre-coders then enter the key-in codes for insurance companies, doctors and modifiers. Pre-coders also add insurance companies, referring doctors, modifiers, diagnosis codes and procedure codes that are not already in the system.

The Coding team assigns the Numerical codes for the CPT (Current Procedural Terminology) and the Diagnosis Code based on the description given by the provider.

Charge Team
In this department we have competent individuals who would first enter the patient personal information from the Demographic sheets. They would also check for the relationship of the Diagnosis code and CPT. They then create 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, which is generally 24 hours.

The daily charge entry then needs to be audited to double check the accuracy of this entry, in other words, this is the check and balance to ascertain that the billing rules are being followed accurately. Also, this department is responsible for verifying the accuracy of the claims based on carrier requirements to attain a clean claim.

Claims Transmission
The Claims are filed and the information is sent to the Transmission department. The Transmission department prepares a list of claims that go out on paper and through the electronic media. Once the claims are transmitted electronically, confirmation reports are obtained and filed after verification.

Paper claims are printed and attachments done, if necessary, we put them into envelopes and sent them to the US for postage and mailing. Transmission rejections are analyzed and appropriate corrective actions are taken.

Carrier Adjudication
The carrier Utilization Review department would then review the claim and after their checks, the claim would then be adjudicated on and processed for payment. Later on, a cheque and an Explanation of Benefits are sent to the provider.

Cash Application
The Cash Applications team receives the cash files (Check copy & EOB) and applies the payments in the billing software against the appropriate patient account. During cash application, overpayments are immediately identified and necessary refund requests are generated for obtaining approvals. Also underpayments/denials are informed to the Analysts.

AR analysts are the key to any group. The claims are researched for completeness and accuracy and work orders are set up for the call center to make calls. The AR analysts are responsible for the cash collections and resolving all problems to enable the account to have a clean AR.

They also research the claims denied by the carriers, rejections received from the clearing house, Low payment by the carriers and appropriate actions are taken. Analyst reviews for global patterns and bulk problems are solved at one instance.

This is the hub of activity around which Medical Billing operates, where we place a call to the Insurance and verify if the claim is with the carrier and what the current status of it is? Whether it is being processed for payment or denial? Based on his inputs the analyst gets to work, and gets all the pre-requisites needed, in case of payment he would compile a list of payment details or if the case is denied, the corrective action needs to be initiated.

The Calling team receives work orders from the analysts and initiates calls to the insurance companies to establish reasons for non-payment of the claims. All reasons are passed on to the Analysts for resolution.

This scenario is then compiled in Excel, for future use when similar problems occur in any other specialty. This information needs to be made available to anyone who needs to review past records to identify solutions to any particular scenario.

Month End Reports
End of the month we would need to run Doctor Financials and other procedure code usage reports, aged summary reports so that we would asses the momentum that has been achieved this month, and if not see where there is a pattern of non payment.

In this way we tackle any bulk or pending issues. Any claim pending beyond the 60th day needs to be acted upon. If it has been pending for clarification then this has to be communicated to the respective account manager at the center so that remedial steps could be initiated.

Confidentiality of Information
Electronic processing and transfer of data via multiplex or /router/ modem is encrypted and password protected to ensure privacy and confidentiality. Dedicated leased lines and Firewalls ensure security of data.

We ensure compliance of The Health Insurance Portability and Accountability Act of 1996 (HIPAA). We respect all patient information provided by our client and will not disclose any information.

Confidentiality of patient and practice information is assured. Proskribe Services has zero tolerance policy for any breech of confidentiality. Records are kept secure and all appropriate laws are observed for handling the release of information.

For Billing Companies
•Submission of clean claims with fewer errors and fewer denials.
•Lower cost structure and highly qualified staff gives us the resources to analyze and resolve denials and to follow up lower-dollar claims and make collections.
•The result is a higher profit for you...

For Hospitals
• Two productivity teams, one for analysis and one for follow-up, pursue even low-dollar uncollected funds which results in cleaner claims and better cash flow.
• While we control your costs, we also boost your revenue.

Our major specialties include:
1. Coding and Billing
2. Maintaining patient’s records and accounts
3. Filing claims to the insurance companies
4. Following up with the insurance companies and patients
5. Assuring high productivity and re-imbursement
6. Strict adherence to rules and laws of insurance companies; Federal Government rules and laws; and HIPAA Guidelines
7. Printing
8. Pre-verification
9. Charges Entry
10. Audit
11. Claims and Transmission
12. Cash Posting
13. Accounts Receivables
14. Compliance