PractiSource Process Workflow
For Clinical Laboratories
PractiSource’s services are provided in a way which is simple for our laboratory clients. Our goal is to maximize revenue while allowing the laboratory to focus on performing tests and growing their business.
Much goes on behind the scenes at PractiSource in providing our services. Below is an outline of some of the basic steps taken to provide our medical biling and Revenue Cycle Management (RCM) services to our customers.
PractiSource imports the electronic files, creates patient records within the PractiSource RCM system, and attaches the appropriate service information to the record in order to generate an insurance claim. All claims are placed in a suspense queue where they are then passed through a series of both human and electronic edits. Electronic scrubbers within the software check claims against things like CCI edits to help ensure that only “clean claims” are sent to payers, increasing the liklihood of payment on the first submission. Additionally, PractiSource has its own proprietary edits which are applied against the claims prior to submission. These edits are updated and modified on a routine, frequent basis and can be payer, procedure and client specific.
Next, PractiSource performs an electronic insurance eligibility check to verify that the patient is currently properly subscribed to the indicated insurance. If a patient has incorrect or expired insurance, the patient information is then researched and updated prior to submitting the affected claim.
Once all of these processes have occurred, PractiSource then performs an additional human review of the claims held in the suspense queue afterwhich they are submitted to insurance.
When a claim is paid, the payment is usually made electronically through an electronic funds transfer (EFT) directly to the client’s bank account along with a corresponding electronic remittance advice (ERA). ERA’s are automatically routed to PractiSource for review and posting. Once received, the ERA is placed in a suspense payment processing queue where it is matched with the corresponding charges, verified against fee schedules, and reviewed by a reimbursement specialist. Once reviewed and approved by the reimbursement specialist, payments, adjustments (and denials) are posted to the appropriate line items on patient accounts. Payment amounts are verified with the client on a routine basis to ensure that all EFT’s have been received and balance to the payments posted in the PractiSource system. Payments which PractiSource find to be incorrectly adjudicated by the payer are appealed accordingly.
Certain claims are not paid electronically, but are rather paid “on paper”, meaning that a physical check (and often a physical EOB) is sent to the client and must be deposited. There are various options on how this information can be forwarded to PractiSource. For example, the client may make their own deposits and then simply forward this information via scanning or mail to PractiSource for processing. A secure scanning account is setup for the client, along with a batch process which ensures that all payments are received by PractiSource, posted correctly and balanced to the penny. Other options include the use of lock boxes or having PractiSource make deposits on behalf of the client. During the implementation process, PractiSource works with the client to determine the most convenient and efficient method. Regardless of method, once these payments are received, they are reviewed, manually entered into the RCM system, and then posted accordingly.
Many patients will have a balance remaining on the charge after the primary insurance makes payment. For patients with additional secondary (or tertiary) insurance, a secondary claim for the remaining balance is generated and submitted to the secondary insurance payer along with corresponding required information such as the primary insurance EOB. Some primary carriers such as Medicare have the ability to send this data electronically to select secondary payers (such as Medicaid). In such instances, these claim balances are tracked and processed accordingly by PractiSource. Secondary payments are processed and posted in a similar fashion as primary payments (above).
Should a patient have a balance remaining after insurance has adjudicated the claim, PractiSource will bill the patient accordingly and in compliance with the client’s patient billing policies (details later).
Claims may get denied by payers regardless of how “clean” the claim is upon submission. Some claims (or portions of claims) are correctly denied by carriers while others are incorrectly denied. Denial information from insurance payers arrives in both ERA files as well as paper EOB’s. Regardless of which method, PractiSource posts all denials into the RCM system along with the appropriate corresponding information and reason codes (for tracking and reporting purposes). “Incorrect” denials are then processed by PractiSource Reimbursement Specialsts who review the denial and reprocess or appeal the claim accordingly.
In certain cases, the Reimbursement Specialist may need to access or request clinical notes or other information from the clients in order to make their case with the payer and get the client paid. During implementation, the client and PractiSource implementation staff will determine the most convenient method of transferring this information. For example, PractiSource staff may request medical notes by sending their client liason a Request for Information (RFI) form outlining information needed. This can be faxed or scanned back. Alternatively, some clients may have the ability to provide PractiSource reimbursement specialists with access to their documentation via electronic means such as LIMS or EHR access.
PractiSource will then submit the appropriate appeals letters or other documentation in an effort to obtain payment for the client. Various appeals techniques and processes are utilized, the specifics of which are determined by the nature of the claim, denial, or individual payer.
Igonored /Non-adjudicated claims
Just because a clean claim was submitted to an insurance carrier, there is no guarantee that the payer will pay or even adjudicate the claim. Payers at times simply lose claims in the shuffle, usually to the provider’s detriment. This fact, combined with timely filing limits, means that such outstanding claims must be followed-up upon and researched to make sure payers are held accountable and pay the claims accordingly.
Most billing organizations (whether internal or external) tend to utilize accounts receivable aging reports to perform this task. Essentially, billing staff print reports and then use these as a guide to determine which outstanding balances should be called upon. Typically, these are run starting at 60 days or so from the date of service or submission. In contrast, PractiSource typically uses a different, more effective methodology for claims followup.
PractiSource has developed and utilizes an insurance-specific rules-driven followup engine to work outstanding claims. In this process, each payer or payer type has associated rules as to when overdue claims should be addressed. For example, one payer may normally pay claims in 20 days. PractiSource may then set its systems to followup on that payers claims on, say, day 25. The system updates automatically, and populates works queues for reimbursement specialists daily. This ensures that claims are followed up closer to the date of service than under standard paradigms. The closer to the date of service a claim is followed-up, the more likely it is that payment will be realized.
PractiSource Reimbursment Specialists use a variety of methods to research and followup claims. These include EDI reports, payer websites, third party sites and resources, as well as telephone calls with payers. Once a claim is researched, the Reimbursement Specialist will take the appropriate action (ie. resubmission, appeal, additional followup), and then note the system with a new followup time, helping to ensure that the claim does not “fall through the cracks”. A great deal of time and effort is spent tracking down potential payments others often overlook. The importance of correct followup can not be overstated as it directly impacts revenue and is a key differentor in billing and A/R management performance.
PractiSource handles all patient billing functions for clients. Most patient billing occurs once insurance (primary as well as secondary if applicable) has paid / adjudicated the claim. Once all payers have appropriately paid their portion of the claim, the remaining balance after insurance adjustments (if one exists) is then billed to the patient on a patient statement. PractiSource patient statements are typically line-item specific, clearly showing the patient or guarantor exactly what the charge was for, along with all corresponding insurance payments, adjustments, credits…etc. They usually also show a reason as to why the patient owes the balance (example: describing that the balance is due to their insurance deductible or similar). By providing detail along with a description of the reason, patients are more likely to pay their balances completely and in a timely manner.
Statements are generally sent daily or weekly, with patients on a 28-day cycle. This means that once it is determined that the patient owes a balance, a statement is generated and mailed on the next day or at the end of the week. If payment is not received, then the next statement goes out approximately 28 days later.
PractiSource has studied the efficacy of various statement and billing methodologies and has found that not only is the appropriate format important (as stated above), but the number and type of statements or letters is critical as well. For example, we have found that simply continuing to send statements to a patient after their second statement has drastically diminished returns. The liklihood of the patient/guarantor paying their bill on a third or subsequent statement is quite small. Therefore, other steps are taken. For example, in place of a third statement, PractiSource generally sends a letter (or letter/call series) to the guarantor indicating three things:
- That previous statements were sent and payment was not received. Accordingly, if these were overlooked, the balance should now be paid.
- A financial hardship provision. This indicates that should there be any questions on the statement, or they con not afford to pay, they should contact the billing office to make appropriate arrangements (PractiSource handles all calls, and can setup budget plans or other arrangements per client policies)
- A dunning message stating that if they do not pay or contact us, that we can only surmise that there is no intention to pay their bill, in which case they may be referred to an outside collection agency (this is dependent upon the client policy)
The exact wording of such letters is reviewed with the client during the implementation processes to make sure it correctly reflects the desires of the client. It may be changed at any time.
Patient Phone Lines
PractiSource sets up patient phone lines specifically for each client. Generally phone numbers are set up to match the clients location, area code…etc. By doing so, we appear as a seamless extension of the client to the patient. Furthermore, these phone lines are answered not as PractiSource, but as the Clients Billing Office (or similar).
With clients from the east coast all the way to Hawaii, PractiSource has phone coverage throughout the United States. All representatives taking patient calls actively work on the client account and are familiar with the billing policies of the client. All representatives are U.S.-based.
PractiSource understands that our clients patients are to them, as they are to us. We treat patients accordingly – with respect, kindness, and with helpfulness. We are there to help explain their bill, take new insurance information, take payment, or assist in any way. PractiSource is not a collection agency and does not threaten or disrespect patients in any manner. This approach not only helps the client/patient relationship, but also tends to improve collected amounts as well.
Patient Payment Portal
PractiSource offers a patient payment portal as well. This portal can be integrated into the clients website and allows patients to log in to view their statements, and pay their bill. Information for the portal is also provided on the statements sent to patients. In addition to online bill pay functions, it also provides the ability to send e-statements.
All of the steps above are critically important to maximizing reimbursement for the client. However, it is also important that clients have proper financial reports and analytics so that they can make the best business decisions. PractiSource provides outstanding and comprehensive analytical data back to the client in various ways. Clients have complete access to PractiSource’s systems for complete control and all patient financial data, transactions, notes, and reports are available to clients at all times.
PractiSource provides clients with system reports which cover all aspects of billing and accounts receivable management. These reports can be run by the client, or may be requested from PractiSource. PractiSource can also arrange to have end of month reports sent automatically to the client electronically, eliminating the need for the client to access the system.
PractiSource provides clients with our industry leading Precision Business Intelligence (PBI) analytics system. This is an interactive reporting and analytics tool which provides incredible insight into your data. Data can be viewed a number of ways, and can be filtered and sorted accordingly. Additionally, reports can be exported (ie. to excel). PractiSource analytics provides you with the detailed information you need to make the best business decisions improve your bottom line.
CLIENT INTERACTION and REQUIREMENTS
So what does a client need to do on an ongoing basis to work with PractiSource? In order to provide services, PractiSource simply needs certain information.
Clients send PractiSource information regarding patients including patient demographics, guarantor (insured) and insurance. The format of this information and the manner in which it is sent may vary. The method is determined and agreed upon during the implementation process. For example, some clients may only have the ability to send this information on paper such as by scanning patient face sheets and insurance cards. Other clients may already have this data in their EHR or LIMS systems which can then be interfaced with PractiSources systems (ie. through HL7 interfaces or other data extracts). In the later case, PractiSource performs the necessary programming to take information electronically from the client’s system, making the transfer of this information an incredibly efficient painless process for the client. By streamlining these processes, clients can concentrate on patient care (driving revenue) rather than catering to their internal or external billing partner.
Patient service information (ie. CPT and ICD data) should be sent to PractiSource on a routine basis. As above, this can be accomplished in a highly efficient way such as through electronic interfaces, although some clients still utlize scanning or other means. Either way, we make working with PractiSource as simple as possible.
While most payments and remittance data comes to PractiSource from payers electronically, there are still instances where paper payments need to be processed. Again, the manner in which payment information is transferred to PractiSource may vary depending upon the desires of the client.
Requests for Information
Occassionally, PractiSource will send a requests for additional information (RFI) to clients. These may come through either paper or electronic forms. An example might be when incomplete information is provided, such as a missing data element (ie. missing diagnosis). Another example would be a request for patient visit notes or lab results. We ask that our clients send RFI information back to PractiSource in a timely manner so we can get them paid quickly!
Routine Client Meetings
PractiSource believes that maintaining open lines of communication is a key factor in optimal outcomes. Every client has a dedicated account representative who works on their account on a daily basis and is therefore highly familiar with the client. Additionally, we find periodic meetings and conference calls to be extremely valuable. PractiSource normally sets up routine meetings or calls with clients in order to review any concerns, as well as to review statistics and performance. The frequency of these meetings is determined by a number of factors, and they are not limited in any way. We view ourselves as a team which works as a seamless extension of the client. PractiSource has a reputation of having fanatical customer service, routine, pro-active client communication is key to our success!
We hope this information is informative. While descriptive, it only represents an overview of what PractiSource does on behalf of our clients day in and day out. Much more goes on behind the scenes to improve revenue while allowing our clients to concentrate on their core competencies. In the end our focus is quite simple- to maximize revenue with the highest levels of customer service and support.
Thank you and we look forward the opporunity of serving you.