Our Services

CREDENTIALING
We will obtain, verify, and asses the qualifications of a practitioner to provide care or services for your health care organization.

Insurance credentialing (or Provider Enrollment) refers to the process of applying to health insurance networks for inclusion in their provider panels. Credentialing is a complicated, tedious and strategic process. PRCM have 10+ years of getting our physicians accredited.

Trust us to get you paid!!
  • Consider establishing a business entity under which to practice (LLC, S-Corp, PC, etc) and obtain your tax ID.
  • If operating as a sole proprietor, consider obtaining a federal tax ID to operate under instead of your SSN.
  • Obtain your professional liability insurance policy.
  • Obtain an NPI number for you individually (type 1) and your business entity (type 2).
  • Be fully licensed in the state where you will provide services (including prescriptive authority).
  • Create a profile with CAQH and keep it current.
  • Have your practice location ready.
  • Know which insurance networks you want to participate with.

Pre-Encounter Services

Pre Authorization/ Prior Certification

Federal, State and Commercial Payers

Insurance Eligibility/Benefits Verification – Basic
advance verification through both web portals and calls

Physician Credentialing – Medicare, Medicaid, Commercials and Workers compensation

Medical Record Review / Code Abstraction / Chart

Summarization – Summary of past medical records

Post-Encounter Billing Services

Coding – ICD 10, CPT, HCPCS, CDT

Coding Review – HCC, DRG, HEDIS

Charge Entry

ERA/EOB posting and reconciliation

Automated claim status services

Insurance AR follow-up, Denials, Appeals

Prior AR evaluation, Re-filing, Appeals, Completion

Revenue Cycle Management
Your dedicated billing specialist will implement a series of steps to ensure that your practice consistently receives service reimbursement beyond industry standards.

The medical billing process is a series of steps completed by billing specialists to ensure that medical professionals are reimbursed for their services. Depending upon the circumstances, it can take a matter of days to complete, or may stretch over several weeks or months. While the process may differ slightly between medical offices, here is a general outline of a medical billing workflow.

Your dedicated billing specialist will implement a series of steps to ensure that your practice consistently receives service reimbursement beyond industry standards.

Patient Registration

Patient registration is the first step on any medical billing flow chart. This is the collection of basic demographic information on a patient, including name, birth date, and the reason for a visit. Insurance information is collected, including the name of the insurance provider and the patient’s policy number, and verified by medical billers. This information is used to set up a patient file that will be referred to during the medical billing process.

Financial Responsibility

The second step in the process is to determine financial responsibility for the visit. This means looking over the patient’s insurance details to find out which procedures and services to be rendered during the visit are covered. If there are procedures or services that will not be covered, the patient is made aware that they will be financially responsible for those costs.

Superbill Creation

During check-in, the patient will be asked to complete forms for their file, or if it is a return visit, confirm or update information already on file. Identification will be requested, as well as a valid insurance card, and co-payments will be collected. Once the patient checks out, medical reports from the visit are translated into diagnosis and procedure codes by a medical coder. Then, a report called a “superbill” may be compiled from all the information gathered thus far. It will include provider and clinician information, the patient’s demographic information and medical history, information on the procedures and services performed, and the applicable diagnosis and procedure codes.

Claims Generation

The medical biller will then use the superbill to prepare a medical claim to be submitted to the patient’s insurance company. Once the claim is created, the biller must go over it carefully to confirm that it meets payer and HIPPA compliance standards, including standards for medical coding and format.

Claims Submission

Once the claim has been checked for accuracy and compliance, submission is the next step. In most cases, the claim will be electronically transmitted to a clearinghouse, which is a third-party company that acts as a liaison between healthcare providers and health insurers. The exception to this rule are high-volume payers, such as Medicaid, who will accept claims directly from healthcare providers.

Monitor Claim Adjudication

Adjudication is the process by which payers evaluate medical claims and determine whether they are valid and compliant, and if so, the amount of reimbursement the provider will receive. During this process, the claim may be accepted, rejected or denied. An accepted claim will be paid according to the insurers agreements with the provider. A rejected claim is one that has errors that must be corrected and the claim resubmitted. A denied claim is one that the payer refuses to reimburse.

Patient Statement Preparation

Once the claim has been processed, the patient is billed for any outstanding charges. The statement generally includes a detailed list of the procedures and services provided, their costs, the amount paid by insurance and the amount due from the patient.

Statement Follow-Up

The last step in the medical billing process is to make sure bills are paid. Medical billers must follow up with patients whose bills are delinquent, and, when necessary, send accounts to collection agencies.

Practice Management
We provide a practice management system that manages the day-to-day operations of a practice, such as appointment scheduling, billing and other administrative tasks.

  • Private Practice. In private practice, a physician practices alone without any partners and typically with minimal support staff. …
  • Group Practice. A group practice involves two or more physicians who all provide medical care within the same facility. …
  • Large HMOs. …
  • Hospital Based. …
  • Locum Tenens.

the solution for independent physicians and hospital-employed physicians who want to improve efficiency and drive revenue at the medical practice while improving the overall patient experience

sometimes referred to as a physician practice management company or an administrative services organization – generally refers to a business entity that provides non-clinical practice management services to a medical practice.

Audit & Consulting
We have expertise in giving advice, and guiding healthcare organizations to make business decisions that promote growth and benefit their customers and patient.

As far as processes are concerned, medical billing audits will cover

    1. Determining the scope of the audit and resources needed to complete it efficiently and effectively. This audit may include understanding clinical staff involved, payer mixes, and composition of billing and coding staff
    2. Assessing the scene of the audit to determine problematic trends or areas of increased risk. An audit also involves checking the frequency of provider services and analyzing CPT code usage by billing staff and providers.
    3. Taking corrective action by using audit results as strategic information to improve revenue cycle management and care outcomes. This includes setting achievable targets for improvement, addressing internal issues that have been identified, and pressuring payers to improve any areas in which they’ve been found lacking.
    4. Learning and repeating the process so that future audits are simpler and easier to carry out. 

Benefits of Billing Audits

Billing audits might seem like a luxury, especially in a busy practice, but performing audits is actually beneficial. Those benefits cover coding, clinical practice, as well as administration. 

1. Coding Benefits

Billing audits are helpful to the coding staff as it provides a way to identify and correct problem spots before the government or insurance payers challenge inappropriate coding. Having someone to rely on to identify inaccuracies and provide instructions on ways to correct issues, builds confidence among the coding staff, and ensures that they use up-to-date procedure codes. Those conducting the audit can identify areas where staff education and training are needed to make sure that proper coding protocol is always followed. With efficient medical coding, the practice is spared a visit from government investigational auditors like RACs or ZPICs.

2. Administrative Benefits

The administrative staff benefits from medical billing audits by confirming that claims are true and accurate and are correctly submitted. Audits set the standard for the office staff and spare them unnecessary frustration by creating a positive, stable work environment and culture of compliance that attracts and retains talented personnel. Under-coding, code overuse, improper unbundling habits are replaced with appropriate billing for commonly documented procedures. When policies and procedures are set in place and followed correctly, the chance of a visit from an external auditor decreases significantly. 

Through medical claims audits, the practice is protected against fraudulent billing activity and claims. When an internal check and balance system is in place, practices can easily verify compliance with ICD-10-CM and EHR Meaningful Use readiness. Incorrect payments are reduced or eliminated. The audit may identify reimbursement deficiencies and reveal ways in which the practice varies from the national average due to inappropriate coding. Thus, areas for increased reimbursement may be revealed and, in turn, boost revenue. Additionally, the practice benefits when files are processed efficiently, improper payments are reduced, and claim payment is optimized. 

An improved relationship with payers is another perk on a medical claims audit. Payers appreciate when claims are submitted accurately. An audit will reveal any outliers that allow the practice to identify any problems before the claims software of a large payer identifies a problem and requests an external audit.  

3. Clinical Benefits

Medical claims audits contribute positively to improved patient care. By tracking and monitoring services and procedures and educating physicians on providing patients with positive medical experiences, the focus of the entire practice shifts to the quality of care provided. When patients have a better experience, the result is a smoother revenue cycle and better patient outcomes.

Overall, conducting billing audits helps a practice understand risk and serves as a starting point for working toward smooth workflows and the best-functioning practice possible.

Additional assistance for your practice

  • EDI Set-up – 276/277 (Claim Status) and 270/271 (Eligibility and Benefits Verification).
  • Indexing – Filing Paper Medical Records in Document Management System or Practice Management System Innovation.
  • Data Migration – Legacy to new PMS while migrating from one billing software to another mutual respect.
  • Customized Reporting – Weekly Clarification Logs, Monthly Review Presentation, Reports taken from Work Flow Management Tool Mechanism.

EHRs/EMRs Experience

  • eClinical Works
  • Kareo
  • Vision – SourceMed
  • Medworxs
  • Office Ally
  • Practice Fusion
  • Epic
  • AdvancedMD
  • Athena
  • ChiroTouch
  • Greenway Private Suite
  • CureMD
  • DocuTap
  • PromptMD

REPORTING CAPABILITIES

  • End of Month ( Provided each month).
  • End of Year.
  • Procedure Analysis/ Per Doctor or Group.
  • Diagnosis Analysis/ Per Doctor or Group.
  • Physician financials by month or year.
  • Carrier Payment Analysis Monthly or Yearly with A/R of Insurance.
  • Payment Allocations.
  • Patient and Insurance A/R.