PCMG Process- HOW IT WORKS
1. CLIENT IS REGISTERED INTO PCMG SYSTEM
A. Client’s current forms & processes are reviewed/updated for accuracy, efficiency & compliance
B. Client is loaded into PCMG system & staff is trained
a. Access to PCMG System, Ebridge EDS
b. EHR interoperability/access/implementation
C. Credentialing Service occurs concurrently (if applicable)
2. CLIENT PROCESS
A. Patient calls to make appointment
1. staff or PCMG verifies benefits
2. pre-certification is obtained (if necessary)
B. Patient is treated
1. staff obtains applicable co-payment/payment
2. staff makes another appointment (if necessary)
C. All applicable data for the patient visit is forwarded to PCMG via chosen format
D. (Any payments that are received in-house initially are forwarded to PCMG)
3. PCMG PROCESS
A. DATA ENTRY & BILLING
1. All received data for the patient visit is scrubbed for completeness and correct coding prior to data entry occurring
2. If any necessary information is missing or if any information given will lead to a denial, a “MISSING” information request is forwarded to the Client for clarification
3. All complete data is entered
4. Data is again scrubbed prior to being billed for applicable CCI/LCD/& other edits
5. All data is billed electronically (*except payers that cannot receive electronic claims- billed on paper)
B. RECEIPTS
1. Most receipts via ERA remittance. Any received at the client’s office should be forwarded to PCMG
2. Receipts are divided into two batches- denials/pends and payments
3. Denials/Pends are given to denials management dept for immediate work
4. Receipts are posted and applied and reviewed for complete & accurate payment
a. Adherence to fee schedule
b. Partial payments are reviewed and given to denial mgmt dept for appeals
C. DENIALS MANAGEMENT (Follow-Up and APPEALS Process)
1. All incorrectly paid or denied receipts (that can be appealed) are appealed according to standard templates and procedures set-up by PCMG
a. Standard templates- CCI edits, LCD adherence, Modifier usage, State Law, WC law, NF law, ERISA regulations, MCO contract & fee schedule, UCR, Silent PPO (etc), timely filing
b. Standardized Phone, Internet, Email, & Fax appeal process
c. 2nd level appeals
d. Complaint Process- State Insurance Commissioner & ERISA
2. FU (Follow-Up) occurs on all claims > 30days
a. Tickler system for FU and Appeals
b. Standardized appeal templates and procedures are used as specified above
D. PATIENT STATEMENTS and COLLECTIONS
1. Statements are mailed to patients
2. 3x statement cycle (90 days)
3. All patient phone calls are answered by PCMG
4. Last statement- collection letter
5. Collection Manager reviews accounts according to guidelines setup by client
6. CD report (Collection Decision Report) gets sent to client for collection decision
E. INVOICE and REPORTING
1. Client is invoiced, payment is due via ACH
2. Client receives desired reports for financial analysis
F. MEETINGS/COMMUNICATION
1. Tailored to client's needs & preferences
1. CLIENT IS REGISTERED INTO PCMG SYSTEM
A. Client’s current forms & processes are reviewed/updated for accuracy, efficiency & compliance
B. Client is loaded into PCMG system & staff is trained
a. Access to PCMG System, Ebridge EDS
b. EHR interoperability/access/implementation
C. Credentialing Service occurs concurrently (if applicable)
2. CLIENT PROCESS
A. Patient calls to make appointment
1. staff or PCMG verifies benefits
2. pre-certification is obtained (if necessary)
B. Patient is treated
1. staff obtains applicable co-payment/payment
2. staff makes another appointment (if necessary)
C. All applicable data for the patient visit is forwarded to PCMG via chosen format
D. (Any payments that are received in-house initially are forwarded to PCMG)
3. PCMG PROCESS
A. DATA ENTRY & BILLING
1. All received data for the patient visit is scrubbed for completeness and correct coding prior to data entry occurring
2. If any necessary information is missing or if any information given will lead to a denial, a “MISSING” information request is forwarded to the Client for clarification
3. All complete data is entered
4. Data is again scrubbed prior to being billed for applicable CCI/LCD/& other edits
5. All data is billed electronically (*except payers that cannot receive electronic claims- billed on paper)
B. RECEIPTS
1. Most receipts via ERA remittance. Any received at the client’s office should be forwarded to PCMG
2. Receipts are divided into two batches- denials/pends and payments
3. Denials/Pends are given to denials management dept for immediate work
4. Receipts are posted and applied and reviewed for complete & accurate payment
a. Adherence to fee schedule
b. Partial payments are reviewed and given to denial mgmt dept for appeals
C. DENIALS MANAGEMENT (Follow-Up and APPEALS Process)
1. All incorrectly paid or denied receipts (that can be appealed) are appealed according to standard templates and procedures set-up by PCMG
a. Standard templates- CCI edits, LCD adherence, Modifier usage, State Law, WC law, NF law, ERISA regulations, MCO contract & fee schedule, UCR, Silent PPO (etc), timely filing
b. Standardized Phone, Internet, Email, & Fax appeal process
c. 2nd level appeals
d. Complaint Process- State Insurance Commissioner & ERISA
2. FU (Follow-Up) occurs on all claims > 30days
a. Tickler system for FU and Appeals
b. Standardized appeal templates and procedures are used as specified above
D. PATIENT STATEMENTS and COLLECTIONS
1. Statements are mailed to patients
2. 3x statement cycle (90 days)
3. All patient phone calls are answered by PCMG
4. Last statement- collection letter
5. Collection Manager reviews accounts according to guidelines setup by client
6. CD report (Collection Decision Report) gets sent to client for collection decision
E. INVOICE and REPORTING
1. Client is invoiced, payment is due via ACH
2. Client receives desired reports for financial analysis
F. MEETINGS/COMMUNICATION
1. Tailored to client's needs & preferences
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