Revenue Cycle Management

• Insurance verification

Insurance verification is a crucial step in the healthcare billing process, ensuring that patients’ insurance coverage is accurately confirmed before they receive medical services. Trained staff or automated systems then verify the patient’s insurance coverage. They confirm important details such as the patient’s eligibility, coverage benefits, policy status, deductibles, copayments, and any pre-authorization requirements. Once the verification process is complete, the healthcare provider’s office is informed of the patient’s insurance coverage details. This information helps determine the patient’s financial responsibility for the medical services they receive.

• Registration / Demographics

Registration and demographics form the initial stage of the healthcare journey, laying the groundwork for effective care delivery, communication, and billing processes. HELPS MD ensures the accuracy and integrity of patient information, healthcare organizations can provide high-quality, patient-centered care while maintaining compliance with regulatory requirements.

• Charge Entry & Submission

Submitting clean claims is the backbone of any successful medical billing process, directly impacting revenue generation. While claim submission may seem straightforward, it requires meticulous attention to detail. Successful billers must ensure various factors are accurately addressed, including patient eligibility, insurance verification, service location, precise matching of ICD-10 and CPT codes, correct identification of rendering and billing providers, facility information, and accurate unit billing (especially for services like anesthesia, pain management, physical therapy, and occupational therapy), along with the billed amount. Any oversight in these areas can disrupt the revenue cycle significantly. Therefore, it’s advisable to entrust the task to experienced and seasoned medical billing organizations such as HELPS MD for timely and accurate submissions.

Understanding the fundamentals of the claim creation process is essential not only for billing staff and outsourced billing companies but also for healthcare providers and their medical teams.

The process of creating a claim commences the moment a patient arrives at a physician’s office or healthcare facility. Patient demographics, including their full name, date of birth, insurance details, and policy ID, must be accurately recorded. During the doctor-patient consultation, it’s imperative for the provider to document all procedures performed along with relevant medical notes. This comprehensive documentation enables professional coders to accurately code procedures and diagnoses, ensuring that medical providers are fairly compensated for their services and efforts.

A significant portion of claim rejections stem from errors in the factors mentioned above, necessitating thorough follow-up efforts to identify and rectify issues before resubmitting the claim. By getting it right the first time, practices can not only increase revenue but also enhance the performance of their medical billing staff or companies.

At HELPS MD, we address this challenge by leveraging our advanced Artificial Intelligence modules. These sophisticated tools meticulously scrub data to identify any discrepancies in CPT codes, diagnoses, modifiers, billed units, and charges. By doing so, we significantly reduce claim aging, ultimately increasing revenue.

With a claim submission pass rate exceeding 98%, HELPS MD demonstrates the effectiveness of our in-house AI tools.

Our team excels at efficiently managing various billing platforms. Our customizable Business Intelligence Modules can seamlessly integrate with any platform, providing a second layer of Claims Auditing and Reporting. These modules enhance our ability to identify issues and ensure clean claim submissions. Best of all, these tools are included as part of our services and are available to all our clients at no extra cost.

Additionally, we prioritize continuous improvement through a robust self-evaluation process within our organization. Every week, senior management conducts a thorough review of employee performance KPIs. Based on this evaluation and the evolving Medicare billing guidelines and NCCI edits, we provide professional training sessions to our staff. This proactive approach ensures that our team remains up-to-date and equipped to deliver exceptional service to our clients.

• Clearing House rejections & Payer rejections

Clearinghouses are intermediaries that process and forward electronic claims submissions from healthcare providers to insurance payers. Clearinghouse rejections occur when the clearinghouse identifies errors or issues with the submitted claims and returns them to the provider for correction before forwarding them to the payer.

To address clearinghouse rejections, HELPS MD billing staff must review the rejection reason provided by the clearinghouse, correct the identified errors or issues, and resubmit the claims for processing. It’s essential to ensure that the corrected claims adhere to the specific requirements of both the clearinghouse and the payer.

Payer rejection, also known as second-level rejection, occurs when an insurance company refuses to process a claim due to errors or missing information. The billing team addresses these issues by identifying errors or discrepancies and making necessary corrections before resubmitting the claims. In some cases, additional communication with the payer may be required to clarify any issues for rejected claims. This process ensures that claims are accurately processed and reimbursed in a timely manner.

• Payment Posting

Payment posting holds significant importance in the medical billing field for several reasons. It serves as a key indicator of the performance and efficiency of the billing staff or outsourced medical billing company. Reduced collections can serve as a warning sign that something may be amiss, prompting healthcare providers to consider changes or outsourcing their billing operations.

The posting of payments and the frequency of cash inflows provide valuable insights into the cash flow cycle and the true financial health of a medical practice. This data informs decisions regarding expansion, investment in new equipment, and the ability to meet operational expenses.

Healthy and consistent cash inflows are evidence of clean and timely billing practices and robust internal processes. To further optimize the revenue cycle, HELPS MD Medical Billing Services assists medical practices in setting up Electronic Remittance Advice (ERA) and Electronic Fund Transfer (EFT) systems.

Collections in medical practices typically consist of three main segments: insurance payments, patient payments, and payments from injuries and worker compensation cases. Insurance payments typically comprise a significant portion, ranging from 80-90% of monthly collections, while patient payments and payments from injuries and worker compensation cases account for the remaining percentage.

Insurance Payments

Proper coding and billing are essential for maintaining a smooth payment cycle in healthcare practices. While many outsourced billing companies prioritize submitting claims to primary insurance, they may overlook the importance of also submitting claims to secondary insurance. However, simply submitting bills to secondary insurances can significantly improve overall collections by 3% to 10%.

Patient Payments

Many insurance plans require members to contribute a portion of their healthcare costs through copays, deductibles, and coinsurance. Ideally, healthcare providers should collect patient responsibilities at the time of the visit. However, some organizations may lack the tools to accurately calculate these amounts, leading to the issuance of monthly statements to patients.

HELPS MD Medical Billing Services assists medical practices in collecting patient payments by sending reminders through phone calls, emails, and patient statements. Typically, three statements are sent to patients, followed by a notice indicating that the account may be moved to collections if the payment is not received. This proactive approach helps ensure timely collection of patient responsibilities, thereby optimizing revenue for healthcare practices

Out of Network/ Injury /Worker Compensation Payments The volume of OON, Injury, and Worker Compensation cases is relatively less but if negotiated right can yield up to 10 times more collections than an average claim payment. Out-of-network and Lien’s cases require a designated payment negotiating team with vast experience in renegotiation and dealing with attorneys. HELPS MD Medical Billing Services is an expert in managing OON, Liens and Worker Compensation cases. We follow the claims from beginning to end by protecting our client’s interest and ensuring a better negotiated rate which demonstrates the ability of our strong internal processes and improve the monthly cash flow.

Payment posting is a process in itself where collections staff not only ensures the received payment accuracy but also highlight underpaid claims and submit the bill to secondary insurances, generate patient statements, move accounts to collections agencies for non-payments, and forward the denied claims to accounts receivables team so it can be timely corrected and resubmitted.

We at HELPS MD are well-rehearsed with the technicality and understanding of the process of payment posting. We recognize the importance of this process and how it can boost the finances of the practitioner. Therefore, our team pays extra attention to every minute detail of this service. Outsourcing your billing to HELPS MD Medical Billing will be a game changer for your practice especially if you run a large practice and have to pay multiple providers towards the end of the month based on their collections.

• Denial management

Denial management is a critical aspect of medical billing that involves the systematic process of identifying, appealing, and resolving claim denials from insurance payers.

The first step in denial management is to identify and categorize claim denials. This involves closely monitoring incoming Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) statements to pinpoint claims that have been denied by insurance payers.

Once denials are identified, the next step is to analyze the reasons for the denials. Denial reasons can vary widely and may include coding errors, missing information, lack of medical necessity, eligibility issues, and policy limitations, among others.

HELPS MD prioritized the denials based on factors such as financial impact, frequency of occurrence, and appeal timelines. High-dollar denials or denials with a significant impact on revenue should be addressed promptly. After identifying and analyzing denials, the HELPS MD billing team initiates the appeal process. This involves gathering necessary documentation, such as medical records, coding information, and payer policies, to support the appeal. Appeals are submitted to the insurance payer according to their specific guidelines and timelines. It’s essential to track the status of appealed claims and follow up with insurance payers regularly. This may involve contacting payers via phone, online portals, or written correspondence to check on the status of appeals and escalate unresolved denials as needed.

To prevent future denials, HELP MD billing experts conduct a root cause analysis of recurring denial trends. This involves identifying underlying issues contributing to denials, such as coding inaccuracies, billing process inefficiencies, or staff training needs. Based on the findings of the root cause analysis, process improvements should be implemented to address underlying issues and minimize future denials. This may include staff training, updating billing policies and procedures, implementing technology solutions, or enhancing communication with payers.

• A/R Recovery

Maintaining a healthy revenue stream is vital for medical practices, and one of the biggest obstacles to achieving this is managing pending accounts receivable, commonly referred to as Aging in the Medical Billing Industry. A flawed claim submission process with inadequate checks often results in denials. If left unaddressed, these denials can lead to revenue loss, as most insurances have timely filing limits after a claim is rejected.

Accounts Receivable (A/R) management plays a pivotal role in the financial health of practices. As a general guideline, pending claims for more than 120 days should ideally be less than 3%. Some specialties, like Anesthesia, may have slightly higher aging, but it should not exceed 5% under any circumstances.

HELPS MD Medical Billing Services takes a unique approach to managing accounts receivable. Our intelligence suite breaks down aging into individual month-wise segments, creating five categories: claims that are 100% paid, claims processed by primary insurers but pending at secondary or patient’s end, partially paid claims, claims in process, and denied claims. These categories enable us to assign claims to relevant teams for corrective action, such as fixing ICD DX and CPT combinations, verifying insurance policy details, and sending medical documents if required. Many commercial insurances require medical records to establish medical necessity for additional procedures.

Patient responsibility related to aging, such as copays, deductibles, or coinsurance, requires comprehensive follow-up, including automatic IVR balance reminders, e-statements, SMS balance reminders, phone calls, and patient statements. Our dedicated bilingual patient engagement team interacts with patients to collect balances over the phone or guide them to make payments online.

To limit accounts receivable, it’s crucial to have an optimal mix of Coding Professionals, Experienced Billers, comprehensive audit practices, and effective procedures in place. Our team comprises qualified medical coders, experienced billers, and a state-of-the-art billing process to ensure claims are properly scrubbed, minimizing potential risks. HELPS MD mitigates A/R rates through a combination of experienced staff, best billing and coding practices, and utilization of our home-grown artificial intelligence auditing suite to scrub claims successfully. As a result, our aging rate is less than 2%. We internally review A/R related KPIs with relevant teams and customers to ensure better management of accounts receivable.

By outsourcing aging or medical billing to HELPS MD, you can rest assured about timely submissions and pending accounts receivables. Experience the improvement, transparency, and visibility that Vigilant brings to your practice.

• Patient Billing

Patient statements are a crucial component of the payment collection process and significantly impact the overall financial outlook of a medical practice. These statements typically outline outstanding balances that insurance plans have left for the patient to pay, including copays, deductibles, and co-insurance benefits, collectively known as patient responsibility.

Managing patient statements requires a considerable allocation of resources and time from practices and healthcare organizations. Often, full-time employees are dedicated to tasks such as printing, mailing, and managing patient statements. However, despite sending out statements, patients may not pay their balances promptly due to lack of clarity and coherence in the statements. Unpaid balances can then necessitate post-statement follow-up calls and SMS reminders. Payment issues may arise when patients struggle to understand billing criteria or have reservations about the dues they owe, disrupting the normal cash inflow for the practice. Consequently, outsourcing to medical billing companies that specialize in generating, sending, and following up on patient statements is highly recommended.

As an industry standard, HELPS MD sends three patient statements spaced 25 days apart, followed by four telephone calls, and ultimately a notice of placing the account with a collection agency in the event of nonpayment of the balance.

HELPS MD offers patient statement services at competitive costs compared to its competitors in the market. We prioritize enhancing patient experience and ease by generating concise, correct, and easy-to-understand bills on behalf of our clients, minimizing patient confusion and irritation during payment processes. To facilitate efficient and timely payments, HELPS MD ensures that our statements accurately highlight the due amount and Date of Service, enabling patients to pay accordingly. Moreover, we take care to list multiple payment options and maintain a patient-friendly tone while communicating payable dues on our statements. Patients can contact us via our toll-free landline or email address, both of which are provided on the statement, if they have any concerns about their bill.

At HELPS MD, customer satisfaction is paramount, and we continually strive for excellence. By outsourcing your services to us, you can avoid the complexities of collecting payments from patients and trust in our expertise to handle the process efficiently.

• Analytical Reports

HELPS MD’s native reporting quickly pinpoints any overlooked revenue opportunities, giving your business a competitive advantage.

Our budget-friendly solutions deliver in-depth Analytics and Reporting on your team’s performance, offering valuable insights to boost employee productivity and efficiency.

We provide weekly, bi-weekly, and monthly reports detailing charges, payments, patient balances, and outstanding claims breakdowns, along with summaries or any customized report. This enables providers to easily assess the overall health of their practices.

2. Credentialing and Enrollment

What is Credentialing?

Credentialing is an essential initial stage for any healthcare provider or entity looking to submit claims. It involves establishing connections with insurance companies to bill claims successfully. Credentialing, in essence, entails gathering necessary documents and submitting them to the appropriate representative to have provider credentials uploaded or updated. This process ensures that the provider’s information is current in the insurance database, facilitating payment for the services rendered.

What is Enrollment?

Enrollment follows credentialing as a secondary step in the process. It involves providers choosing to participate or not in insurance networks, and determining their status as participating or non-participating providers. Being enrolled is just as crucial as being credentialed, ensuring providers can effectively engage with insurance networks and access the benefits of participation.


Why Credentialing is Important?

Credentialing & Enrollment are increasingly becoming important in the healthcare industry as healthcare organizations & providers are looking for ways to ensure greater patient safety, reduce costs, as well as protect healthcare institutions from harm. Assessing and confirming the qualification of healthcare professionals can save healthcare organizations & providers from several liabilities, including fiscal loss, incompetent healthcare providers, risk of compliance violations, and unwanted lawsuits. To have a solid patient base, a healthcare professional should consider being credentialed with insurance. Also, Credentialing improves patient trust in chosen healthcare providers and helps them prevent revenue loss.

WHY HELPS MD?

Gain full access to our transparent Credentialing system, allowing you to track your progress with complete visibility. Experience improved turnaround times for your provider enrollment applications and contracting processes. Benefit from 24/7 support provided by experienced staff who serve as your advocates with insurance companies. Access strategic and detailed reports anytime, anywhere, providing updated statuses at your fingertips. Receive breakdowns by each entity and facility, ensuring clarity on your credentialing status. Collaborate closely with our Billing Team/Operations to ensure smooth submissions and prompt claim releases upon approval. Store copies of contracts and e-contracts in a shared path, granting clients access. Stay informed with bi-weekly and weekly spreadsheet rotations, keeping you up-to-date on interactions with insurance and facilities. Embrace paperless applications where applicable, minimizing setup time. Trust our specialized team to maintain your CAQH profiles and ensure no certifications expire. Rest assured with our systematic checks and balances on every aspect of the process.

Insurances

Commercial Insurance Provider Enrollment and Credentialing & Re-Credentialing (Blue Cross Blue Shield, Anthem, Cigna, Aetna, Humana, United Healthcare, Tricare, and any other plan) Medicare and Medicaid Provider Enrollment and Credentialing Medicare and Medicaid Revalidation PECOS training videos on request CAQH Registration NPI Registration (Type I and Type II) Licensing (new and renewal) Negotiations on rates and reimbursements Address change projects Claims submission setup and electronic remittance setup (837/835) Electronic funds transfer or direct deposits setup.

Ongoing Monitoring and Updates

We provide ongoing oversight to ensure that your company’s credentials remain up-to-date and that you maintain uninterrupted credentialing status. Our experts meticulously monitor your credentialing expirations and perform thorough daily and weekly reviews to keep your credentials active. With us, you can have peace of mind knowing that your credentials are diligently managed and maintained by our team.

3. MEDICAL CODING

Medical coding is a vital process in the healthcare industry, where trained professionals, known as medical coders, translate complex healthcare information into standardized alphanumeric codes. These codes encompass diagnoses, medical procedures, services rendered, and equipment used by healthcare providers. This crucial information is extracted from various sources such as physicians’ transcriptions, laboratory test results, and medical documentation.

The accuracy of medical coding is paramount as it directly impacts revenue generation. Incorrectly coded claims can result in denials, disrupting the cash flow cycle of healthcare organizations. Therefore, it is essential to rely on the expertise of certified medical coders to ensure the accurate transformation of medical charts into codes, facilitating the submission of clean claims.

At HELPS MD, we take pride in our certified and experienced team of medical coders who understand the significance and intricacies of converting medical information into accurate codes. Our coders adhere to the guidelines provided by regulatory bodies such as the Centers for Medicare and Medicaid Services (CMS) and commercial payers. Additionally, they prioritize data accuracy, security, and confidentiality to maintain compliance and protect patient information.

The decoded information from medical charts and documents provides crucial insights to payers, including diagnoses, treatments administered to patients, services provided, and any unique medical conditions affecting treatment protocols.

Our medical coders are not only quality-conscious but also time-efficient, equipped with the necessary tools and skills to streamline the revenue cycle for our clients. Once medical data is accurately coded, it is transferred to our billers who utilize advanced AI techniques to further scrub the data for any errors or discrepancies. Following thorough verification, our billers submit the claims to payers.

Thanks to the expertise of our experienced medical coders and billers, HELPS MD boasts a clean submission rate exceeding 98%. Moreover, we maintain an exceptional first-time pass rate (FTPR), ensuring minimal rejections or delays in claim processing. By outsourcing our comprehensive services, our clients can significantly enhance their financial performance and operational efficiency.

4. Patient Help Desk

HELPS MD patient help desk serves as a central point of contact for patients seeking assistance with their billing inquiries and concerns. At HELPS MD, our Patient Help Desk serves as a dedicated support center for patients, handling calls on behalf of healthcare providers. Our goal is to assist patients with various needs related to scheduling, rescheduling, and canceling appointments. When patients reach out to us, our trained representatives are ready to provide prompt and efficient assistance. Whether it’s scheduling a new appointment, rescheduling an existing one, or canceling an appointment, we aim to make the process as seamless as possible for patients. Our team understands the importance of patient convenience and provider efficiency. We work closely with both parties to ensure that appointments are arranged according to their preferences and availability.

By entrusting their appointment-related inquiries to our Patient Help Desk, healthcare providers can focus on delivering quality care while we handle administrative tasks with professionalism and care.

The patient help desk is the go-to resource for patients seeking clarification on their medical bills. Patients often reach out with questions about charges, insurance coverage, payment options, and explanations of benefits.

Our dedicated team of trained representatives at the help desk is committed to providing patients with accurate and detailed information about their billing statements. They take the time to explain various charges, clarify insurance coverage details, and guide patients through the billing process step by step.

When patients encounter billing issues or discrepancies, our help desk team steps in to assist. This involves investigating any errors, coordinating with insurance companies, and facilitating adjustments or corrections to billing statements as needed.

We understand that managing medical expenses can be overwhelming, so our help desk also offers guidance on payment options and available financial assistance programs. Whether it’s setting up payment plans or exploring assistance resources, we’re here to help patients manage their bills effectively.

Insurance coverage and claims processing can often be complex topics for patients. That’s why our help desk team acts as a liaison with insurance companies, addressing inquiries, resolving claim denials, and assisting with appeals on behalf of patients.

Operating with empathy and compassion, our representatives recognize the stress that billing issues can cause. They provide support and reassurance, listening attentively to patients’ concerns and offering personalized assistance to ease their worries.

Beyond addressing immediate concerns, our help desk is dedicated to patient education. We empower patients with knowledge about billing processes, insurance terminology, and effective navigation of the healthcare system. This equips patients with the tools they need to better understand and manage their medical expenses.

Every interaction with patients is meticulously documented for reference and follow-up. We ensure that patient inquiries are handled promptly and thoroughly, with ongoing communication as needed to achieve resolution and satisfaction.