How to Optimize Medical Billing Services with Revenue Cycle Management

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ehr software chart on ipadThe purpose of this paper is to align our services more closely with the needs of our customers and to make this information publicly available. The research, performed by our staff researchers, focused on some of our key competitors in the Revenue Cycle Management (RCM) market, and their offerings, which resulted in a value score of each RCM company. We hope you find this information useful in determining the value of PrognoCIS RCM and as a discussion of RCM in general.

What are the Differences Between RCM vs. Medical Billing Services?

The terms “medical billing” and “RCM” are used almost interchangeably, but before beginning our discussion, let’s consider the differences between the two. Medical billing service refers to the paperwork of filing medical claims for reimbursement. RCM, on the other hand, includes a variety of additional services—reporting and analysis of the financial pipeline and patient financial services—all the necessary tasks required to get the bill through, beyond simply filling out and filing the paperwork.

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Challenges in Medical Billing and Claim Reimbursement

For any medical practice—family medicine, occupational and environmental, pain management, etc.—billing duties consume an enormous amount of time and resources. The duties of the administration include assembling all relevant data concerning medical bills and ushering this information through a complex and distributed reimbursement system. Managing every single claim includes entering the charges, transmitting claims for payer review, following up with patients and insurance companies and posting payments—and if things are not going well, because if the claims are not ‘clean’ as we call them it will result in corrected claims, appeals, and further delay in payments which is just the beginning of recovering revenue for providing medical services.

If there are any discrepancies that cause the bill to be flagged, it calls for further clarification before the payer can accept the bill as valid. An example of this kind of flagged discrepancy might be of a charge submitted for the application of stitches to a laceration, and the code for the stitching kit sutures is not concurrently included, or a simple manual error of entering a wrong digit in one of the 75,000 codes used in the current internationally recognized disease database. These errors require additional communications to verify services or products being charged and can result in long delays in reimbursement.

Upon submission of a medical claim to institutional payers (like Medicare, or private insurance companies) computer algorithms automatically scan bills in search of errors in coding for the purpose of accepting or denying reimbursement. The complexity of entering this billing information alone requires specialized training, which is just one piece of the puzzle of smooth revenue cycles for the practice. Then, if the computer rejects a claim, resolving any discrepancy issues can be as much an art as it is a science.

Integrated PrognoCIS EHR and RCM vs. Other Billing Services

When determining how your medical practice will carry out medical billing, there are a variety of options to review. The most frequently considered options are to either have a full-time employee dedicated to the task or to outsource these responsibilities. It has been found that providers actually need to hire a biller who is entirely dedicated.  Billers who are partially dedicated tend to not have time to do the follow-up work required to get the claims paid. Since having access to the medical record is required to sort out a discrepancy for a billing issue, having an in-house biller on staff is a convenient option in terms of ready access in order to address issues, however the many distractions of the clinical environment work against this idea.

The other common option is to outsource to a billing agency. However, they do not have the record-level access, as they only see the billing information and not the medical service performed in association with a clinical procedure code (CPC). Using RCM services from a company which provides the Electronic Health Record software and medical billing software solves both of these issues by dedicating full-time people who have the access to information all in a single screen.

The challenges of having an in-house biller include handling all the day to day tasks of employee and facilities management, marketing and providing patient management, while at the same time performing necessary billing tasks. Smaller medical practices lack the resources to have extra staff to meet all these requirements.

PrognoCIS RCM Services deliver a team of at least four dedicated experts per account, including a client Manager, an account manager, an A/R manager, and a credentialing professional, upon request. This streamlines the medical billing beyond what a single in-house biller can do. For a larger practice PrognoCIS deploys a team of more than four experts. PrognoCIS EHR system is integrated with Practice Management Software, meaning that billing and electronic medical records can be managed in a single solution.

These features are what make PrognoCIS medical billing services efficient and accurate while maintaining cost-transparency and greater communication with the patient. The boost in productivity that PrognoCIS brings the medical practice leads to better healthcare, higher levels of patient satisfaction and confidence.

Improved Billing Results with PrognoCIS RCM Services

PrognoCIS RCM services submit claims for over $1 million in A/R monthly for ambulatory medical practices. Our specially trained account managers process claims quickly and accurately, and our medical billing staff is highly trained, certified professionals with hundreds of years of combined experience. They include Certified Procedural Coders (CPC), Masters and Bachelors Degrees in Healthcare Administration and management.

You and your practice benefit from the best possible knowledge and acumen. Our goal for your accounts is that they spend fewer than 45 days in Accounts Receivable (A/R), and 85% of A/R billing is completed before the first 90 days. The RCM team follows up on all unpaid claims after 25 days.

Our services are tailored to your business’s current needs for maximum growth potential. With our account managers, the person handling your medical billing knows your practice well and therefore performs the best service. Your claims are always ready for submission for payment because they are reviewed by certified, professional coders.

Our call centers throughout the U.S. have reps who also have extensive billing experience and can give phone support whenever you need it. PrognoCIS engineers simplify complex information such as an explanation of benefits (EOB) by creating simple, easy-to-read dashboards, so you can always focus on what’s important. The information you need is right at your fingertips.

PrognoCIS partners with Tier 1 clearinghouses like TriZetto Provider Solutions. TriZetto dispenses feedback on our client’s reimbursement data which shows 10% of clients being in TriZetto’s “99% Club.” Over a 3-month time period, these clients have been reimbursed on over 99% of their claims for each month. Clients who use PrognoCIS RCM services are two times as likely to earn acceptance into the 99% club as those who use our Practice Management software alone—as the volume of claims increases, the RCM service rate decreases.

PrognoCIS RCM Claim Management Features

After medical coding is complete, our team performs claim scrubbing to make sure the claims are error-free. Our medical billers perform claim processing whether the claim is filed electronically, or on paper. In the event that a claim is denied, our team will conduct denied claims management. We also bring you eligibility verification prior to patient appointments.

Medical Debt Collection Services

PrognoCIS also partners with Transworld Systems, Inc. (TSI) to offer a suite of services that reduce the volume of delinquent collections and encourage rapid resolution of past-due patient balances directly to the practice. These services are done with a diplomatic approach and are highly effective for recovering the greatest amount of payments for medical services while maintaining a healthy relationship between the provider and the patient. TSI services also include claim follow-up, granular per-patient accounting, and collection agency reports in order to give you a clear picture of the entire debt collection pipeline in summary.

How the Competition Measures Up With PrognoCIS

Several other companies offer medical billing services alongside EHR software, so what differentiates us from our competitors?

PrognoCIS’s dedicated account managers yield a high value to our customers, and many other RCM companies don’t dedicate an account manager to a specific practice, with which they become extremely familiar.  A dedicated manager can also greatly assist in quickly resolving account-specific issues. Our account managers make sure that the practice’s every need is met, and the special attention they provide helps us to understand the workflow beyond what our competitors can, which enables us to refine our services. The personal touch and relationship that come with this service give you confidence that your billing is being properly handled. Dedicated account managers are there to understand your business and increase your potential for
business growth.

PrognoCIS partners only with Tier 1 clearinghouses in order to make sure that the margin of error is as small as possible. Our medical billers meet the highest standards for qualification in the industry, with certifications including CPC and Masters Degrees in Healthcare administration and management. At a 98% first-time claim approval rate, we surpass many of our top competitors.

The services PrognoCIS offers enable you to keep track of your revenue through monthly business analyses which contributes to a successful business strategy. The relatively low cost of our services is an additional benefit to your practice’s growth.

Features that come from our industry-leading EHR, like integrated patient payments and mobile apps, deliver a higher functionality than our competitors can to help you run your practice. Additional features such as eligibility verification, patient estimation (quotes), and Medical credentialing are also conveniently available upon request.

When a practice subscribes to RCM with PrognoCIS, they receive the complete solution of an industry-leading EHR software and a staff of certified professionals who handle all the practice’s claims. Other professional services can supply you with the use of their billers, but PrognoCIS gives you a dedicated staff that works closely with your practice.

With a specialized team to manage your medical claims, you have people who know your business well and therefore can help to maximize your business growth. The increase in productivity that comes from subscribing to these services results in a healthy, growing medical practice, and enables you to focus on what you do best as a medical practitioner: providing care for patients.

PrognoCIS’s RCM services are used by hundreds of doctors at over one hundred sites and in every state. Of those sites, almost half of them have a 99% acceptance rate for medical claims. Leading clearing houses like Trizetto work with PrognoCIS to ensure your claims are error-free. Medical practices with PrognoCIS RCM have a simpler, faster and easier payment experience, at a total lower administrative cost and are two times more likely to enjoy a 99% reimbursement rate. Subscribe to PrognoCIS RCM services to begin receiving these benefits and greater peace of mind.

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