MD CREDENTIALING SERVICES AND PROCESS WORKFLOW

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+1(844)-MD-GUIDE
ONE STOP SHOP FOR RCM SERVICES.
TRUSTED PARTNERS OF MEDICAL PRACTICES

2. Revenue Cycle Improvement System
REVENUE CYCLE IMPROVEMENT SYSTEM
Identify
actual/
potential
problems in
RCM cycle
PLANNING
Benchmark
base
performance
to industry
standards
IMPLEMENTATION
Develop
Management
Reports
Constant
process
improvement
to eliminate
problem
Implement
Changes, Set
Productivity
& Provide
feedback
Continually
monitor
performance.
RESULT
Increased Practice /
Provider Revenue
Fewer Rejections &
Denials
Fewer Write-off’sEnhanced Cash Flow
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3. Auto-regulating Process Flow to Increases Revenue, Enhances
Cash Flow and Reduces Write-Off’s
Proper input of patient
insurance info & codes
into the billing software
Delay in submitting
claims at the year
beginning (to reduce
no. of deductibles
Timely follow-up &
No resubmissions
without carrier calls
Involve patients in the
process for faster
payment
Cycle billing method
for patient statement
and three statements
scenario for
collections
Verify address /
insurance change at
every encounter
Insurance Eligibility
& Verification
24 hrs TAT by
submitting claims
on same day
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4. Scheduling and Patient Registration
99% accuracy with process for
gathering complete patient
demographic information
reduces 20% of rework
Process-oriented Insurance and
Eligibility verification leads to
faster payment within 20 days
Process based verification of
patient ‘s plan benefit, results in
prompt 80% POS collections
MD
Credentialing
Problems
• Inaccurate / Incomplete
patient Demographic
Information
• Inaccurate /
Incomplete
Insurance information
• No verification of
financial
information
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• Losing clients for
Non Network

5. Charge Posting
Process based insurance
verification keeps
resubmissions ratio to claim 2%
Good knowledge of insurance id
formats and an extra minute
spent to recheck insurance keeps
claim rejections below 2%
Separate process step reduces
authorization and referral
denials to 5%
Problems
• Duplicate Charges
• Un-posted Charges
• Wrong Insurance
Selection
• Missing Authorizations
& Referrals
• Neglecting Payer
Contracts
Process step for generating
charge reports and regular
contract updates ensures correct
contract details and keeps
contract denials under 1%
Process based posting and
submission of all services bring
down TFL exceed denials by 99%
and reduce revenue loss by 2-5%
20% additional effort in charge
entry with random Q.C. reduces
duplicate charges & time spent
chasing wrong AR by 5%
MD
Credentialing
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6. Sherpa’s process for secondary re-
submission by printing or uploading
the primary EOB’s brings loss of
revenue down from 10% to 2%
Ensure accurate analysis of EOB
and bill correct patient balance
to avoid compliance issue
Facilitate EDI agreements with
insurance companies. Leverage
electronic posting to track
payments and to bring down AR
Balance to 15%
Payment Posting
Problems
• Lack of reconciliation
• Patient statements
with wrong patient
balances
• Ignoring secondary
payment submission
MD
Credentialing
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7. Ensure claims submission to
insurance with auth/referral & Retro-
auth appealing
Process-oriented COB verification
Denial analysis and prompt
appealing
Denial Management
Problems
• Medical necessity
• Non-Covered
Services
• Co-ordination of
benefits
MD
Credentialing
• Prior-Authorization
/ Referral
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8. Process-oriented insurance
correspondence with necessary
actions (e.g., Medical Records,
Primary EOB etc.,) eliminates
payment delay
Improved claims appeal process
prevents up to 20% loss in
revenue
Prioritize work on Old AR and
try to collect >7% of old claims
Improved workflow process and
increased productivity using our
proprietary AR tracking
spreadsheet to prevent 30%
loss in revenue.
Insurance Follow-up
MD
Credentialing
Problems
• Lack of proper follow-up
•Lower Pending claims
never worked
• Erroneous claims that
are not resubmitted
• Ignoring claims appeal
• Ignoring insurance
correspondence
• Ignoring Old AR
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9. Self-pay Follow-up
Problems
• Incorrect data collection at
front desk
• Statement sent to wrong
address
• Rendering
Non-Covered services
• Inadequate patient
contact
Leveraging experienced patient
account representatives to lower Bad
debt adjustments from 20% down to
under 5%
Proper insurance eligibility
verification along with benefit plan
to eliminate non-covered service
denials
Getting correct patient address from
USPS & verifying with TP software
(e.g., White pages) to avoid sending
statement to incorrect address
Sherpa’s
Solution
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10. Privacy Confidentiality & HIPAA Compliance
• Secured Premises- guarded 24*7
• All employees signed to a confidentiality agreement
• Restricted and monitored internet access
• No media drives
• HIPAA compliant Secured Data transmission
• HIPAA compliant products and procedures
• Frequent training and trouble-shooting per HIPAA guidelines
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