As a Medical Billing service provider company, we have
complete understanding, knowledge and expertise to accommodate
all the complexities of the US health insurance industry
in an efficient way, and as economically as possible.
We are a group of highly dedicated, thoroughly trained
medical professionals bringing along an average of four
years of medical billing industry experience. We have
developed a most comprehensive medical billing workflow
process on the basis of analysis and review of health
insurance’s most complex taxonomy of patient intake/registration,
diagnoses and treatment plans, claims submission and financial
tracking, third party reimbursements, individual patient
responsibilities, and so on.
Before commencing any work on a new project, we undertake
in-depth study and analysis of client’s existing business
function. On the basis of this analysis, we work out a
most comprehensive solution at a highly reasonable pricing
package. We will then implement a strategy that parallels
client’s requirements and sets in place a tangible tool
to measure success. This enables our clients to have industry
standard quality services coupled with 33% to 50% cost
savings while they have adequate time and peace of mind
to concentrate on their core business functions.
Cres-Tech Medical Billing Services: We
offer complete medical billing and insurance claims processing
services including; Downloading and Verification of Charges,
Data Entry of Charges, Accounts Receivable Follow-ups
with Private and Public Carriers, Payments Postings.
Our Strengths
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We are a company that comprise of healthcare
professionals with an average experience of four years
plus in the MT and Medical Billing industry.
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The National Standard Format (NSF) flat
file format is used to bill physician and non-institutional
services, such as services performed in hospitals.
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We apply the latest technology and management
techniques to solve the problems identified by doctor’s
offices.
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Our customer driven focus enables us
to forge true partnership to improve billing and collections
process and minimize the delinquent accounts.
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We hire, retain and provide continual
education to the best human resource in the industry.
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Together with our clients, we pre-define
client satisfaction objectives and then meet or exceed
them.
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We are proud to comply with AHIMA and
HIPAA standards and guidelines to provide quality services.
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Patient information and health insurance
records are maintained for a minimum period of six years
as per Omnibus Budget Reconciliation Act (OBRA) of 1987.
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Downloading of patient’s scanned documents
from Doctor’s Office through secured and dedicated links
strictly complying with HIPAA standards
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Highly accurate Data Entry of charges
and generation of CMS-1500 (HCFA-1500) and UB-92 claim
forms within the allotted turnaround time (TAT) limits
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Transmission of electronic claims to
the US clearinghouses through secured and dedicated
links and paper format claims to the insurance carriers
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Continual follow-ups with insurance
carriers through state-of-the-art contact center to
ensure rapid collections and maintaining a clean AR
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Highly accurate payments postings and
daily, weekly and monthly reports generations as per
the clients requirements
Medical Billing
Workflow
Medical Billing Job Handling for Clients
We have the capacity to handle the following workload
of clients in various departments:
Data Entry Department:
Generation of CMS-1500 (HCFA-1500) and UB-92 claim
forms. At present, we can handle 600 forms per day.
The capacity can be enhanced as per the clients’ requirements
in a phased development process.
Individual
Productivity: Each agent keys in 300 charges
with 0% error rate, we work on two-shift basis to
achieve 100% capacity utilization.
Turnaround Time (TAT): All charges are accomplished
within the agreed turnaround time with the client,
which is generally 24 or 48 hours.
Audit/Review:
Quality is ensured through implementation of rigorous
two-tiered audit/review process. Each agent reviews
100% work at the time of keying in the charges to
enter correct information. The daily charge entry
is then audited by the team lead to double check the
accuracy of the entry. In other words, this is the
check and balance to make certain the billing rule
is being followed accurately. This department also
verifies the accuracy of the claims based on carrier
requirements to ascertain a clean claim. |
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Accounts Receivable Department:
Turning over accounts receivable into cash requires a
systematic, planned and focused approach. Each effort
must be aimed at eliminating or resolving the problem
instead of merely gathering information. Documentation
of the findings is critical as it helps as a reference
tool for the future.
Please click on the link “A/R Management
Process” to learn more about the A/R management process
followed at Cres-Tech.
The problem researched by A/R agents could be an internal
data entry error, incorrect information on the claim,
non-covered benefit, unauthorized procedures and services,
procedure or service not medical necessity, pre-existing
condition, termination of coverage, failure to obtain
preauthorization, out-of-network provider used, lower
level of care could have been provided etc.
Working on delinquent accounts:
Working on delinquent accounts:
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Verifying health plan identification
cards on all patients.
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Determining patient’s health care coverage
to ensure that a pre-existing condition was not submitted
for reimbursement on the claim.
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Electronically submitting a clean claim,
which is correctly completed standardized claim CMS-1500
(HCFA-1500) or UB-92.
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Contacting the payer to determine that
the claim was received.
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Reviewing records to determine whether
the claim was paid, denied, or is in suspense (pending)
such as subject to recovery of benefits paid in error
on another patient’s claim etc.
Submitting documentation requested by the payer to support
the claim.
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Through our state-of-the-art call centre
we have the capacity to make 90 follow-up calls to private
and government insurance carriers on daily basis as
per the work timings of EST, CST and WST insurance carriers
to expedite the collections process.
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The capacity can be enhanced as per
the clients’ requirements in a phased development process.
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We are geared up to fulfill the clients’
target of maintaining less than 5% AR with accounts
aging 120 to 120+ days.
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Our A/R agents are trained and experienced
to ask for EOBs, filing the appeals, sending physicians
enrolment forms, change of address letters, additional
documentation, and corrected claims.
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Payments postings in clients systems
as per the Check amount and EOBs.
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At present, we can handle 600 EOBs/Checks
per day.
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The capacity can be enhanced as per
the clients’ requirements in a phased development process.
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We ensure that 100% accuracy rate in
payments postings is maintained through a two-tiered
audit/review process consequently resulting in balancing
of all the batches at the end of the day.
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We take immediate actions on under-paid
and over-paid claims with appropriate information to
A/R team to file appeals and posting of excess amount
in the suspense account.
A/R Management Process
Turning over accounts receivable into cash requires a
systematic, planned and focused approach. Each effort
must be aimed at eliminating or resolving the problem
instead of merely gathering information. Documentation
of the findings is critical as it helps as a reference
tool for the future.
Accounts Receivable Workflow:
Evolving Benchmarks by Payers:
The first step in understanding the different payers is
to establish benchmarks for their processing. This is
usually obtained from historical information like the
earlier paid EOB’s (Explanation of Benefits), Denials
mails, Manuals and Newsletters. The benchmark should address:
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Time frame to process the claim by
the carrier.
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Requirements such as provider number,
tax ID number, pay to address etc.
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Check lists for the requirement of the
carrier for all blocks in the CMS-1500 (HCFA-1500) claim
form.
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Attachments, referrals and additional
documentation.
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Different plans deployed by the payer
and card copies of the plans.
Identification of Claims Outside Benchmark:
Once the benchmarks are established, it is essential to
identify medical claims falling outside the benchmark
on a weekly basis to quantify the volume and value of
such claims. This can establish and identify a global
pattern, which may affect the majority of claims.
Prioritize Medical Claims to Work On:
Once the medical claims outside the benchmark have been
identified, the next step is to identify the claims to
work on. This is done with the help of reports of claims
by payer type and can then be prioritized and resolved.
While prioritizing the medical claims, the fillings limits
by the carrier will have to be considered which is very
important.
Identifying of Problems:
This is the most important step. The problems and resolutions
to the various scenarios are analyzed, understood and
documented on paper. Because of the complex regulations
governing the medical insurance business, Insurance companies
have devised various complex rules before paying a claim.
The problem could be an internal data entry error, incorrect
information on the claim, non-covered benefit, unauthorized
procedures and services, procedure or service not medical
necessity, pre-existing condition, termination of coverage,
failure to obtain preauthorization, out-of-network provider
used, lower level of care could have been provided etc.
When the problems are researched for solutions we document
the sources of information. It is also essential for resolved
problems to be applied to other claims pending to the
carrier to ensure that the same problem does not recur.
Prepare an Action Plan:
As soon as we identify the problem, the next step is to
confirm the findings. This is done by giving it to the
calling team who will confirm the understanding of the
problem and gather additional information on the reasons
that have caused the medical claims to get rejected.
Preparing an action plan will involve deciding the ways
to get the claims paid faster. An action plan will decide
the steps to be taken, including sending physicians enrollment
forms, change of address letters, additional documentation,
and corrected claims.
Implement the Solution to All Outstanding Claims:
Once the action plan has been drafted and confirmed the
next step is to implement the solution to all the outstanding
claims that fit the criteria for such action. This is
vital since problems falling into the same category are
fixed at one go.
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