The PGM Medical Billing Process

Medical Coding 1

Charge Upload2

Claims Review3

Claim Submission4

Payment Posting5

Claim Tracking6

Denial Management 7

Patient Balances 8

Reporting 9

Medical Coding

According to the AMA, the average medical practice submits more than 50% of its claims with incorrect codes. Inexact and inconsistent coding increases the risks of undercharging, overcharging, and post-payment audit.

At PGM, all of our clients undergo a practice evaluation where our Certified Coders, in conjunction with our Reimbursement Specialists, analyze practice procedures and codes to make recommendations that ensure accurate and optimum reimbursement.

Patient Charge and Demographic Data Entry/Upload

Patient demographics and charges are collected from your office daily. Data can be scanned, faxed, or couriered to any one of our locations. Once the data has been received, a dedicated PGM Account Representative will enter the information into our practice management system.

For PGM clients using an electronic medical record system EMR/EHR, patient demographics and charge data can be electronically transferred in real-time to our practice management system though our EMR/ medical billing interface.

Claim Review

PGM’s Reimbursement Specialists compile and review all client patient and charge data. Billing uploads and batches are balanced, and our medical claims process software is used to ‘scrub’ claims for errors and omissions. PGMs software performs thousands of checks, including CPT/ICD-9 validations, modifier checks, demographic comparisons and payer specific edits.

The claims review process ensures that practice billing data is being accurately captured, and that claims are clean prior to being submitted for payment. Clean claims greatly increase the rate of payment, helping to maximize the amount collected and reduce accounts receivable.

Claim Submission

Once the claims are reviewed and audited, they are transmitted to the various payers for reimbursement. PGM has the ability to electronically transmit claims to thousands of payers nationwide. For those payers that do not have the ability to receive electronic claims, PGM will generate and mail paper claims.

After submission, claims receive an additional level of “scrubbing’ by our clearing house. Edits and errors are relayed back to PGM for correction.

Payment Posting

Payments are received either hard copy or via electronic remittance advices (ERA). PGM clients are given the option to continue to receive payment at the practice or to have PGM manage all payments at one of our facilities.

Once payment is received, it is reviewed and line-item posted into our practice management system by one of our Reimbursement Specialists.

Claim Tracking

Once payments have been posted into our practice management system, they are run through our payer specific rules software, which aggressively detects unpaid or mis-adjudicated claims. Once an unpaid or mis-adjudicated claim is flagged it is brought to the attention of one of our Reimbursement Specialists for further investigation and active follow-up.

Denial Management and Follow-up

Only 70% of the average medical practices insurance claims are ever paid by insurance providers. While a practice may submit a perfectly clean claim to a payer, there is no guarantee that it will get paid, or for that matter, get paid accurately.

It’s no secret that payers continue to impose increasingly complex rules, systems, and loopholes with the single goal of limiting payment. This frequently means that practices remain unpaid on the valuable service provided to patients.

PGM’s incentive based fee structure, ensures that we work hard to make sure nothing gets left behind. Once an outstanding claim has been identified as past due, PGM’s system alerts our Account Representative who then reviews the history and follows-up on the claim accordingly.

Patient Balances Billed

At PGM we understand that patients are the lifeblood of the practice. We work directly with the practice to custom tailor a patient billing profile to perform all patient billing functions on behalf of the practice.

The typical patient billing profile includes a series of easy to understand statements. Should a patient fail to make payment, additional letters and/or a call sequence is initiated. For questions regarding a bill, patients are provided a toll-free number to call where one of our patient Billing Specialists is ready to answer any questions.

PGM does not perform collection services, and therefore patient billing services are structured to encourage patients to resolve outstanding balances. For those patients who refuse or are unable to complete their obligation, PGM will work with the practice to structure a patient payment plan or transition the balance to a third-party collection agency for resolution.

Reporting

PGM provides advanced financial and practice analysis tools designed to give enhanced visibility into practice operations at the click of a button. Practices are provided access to PGM-online, our internet based reporting system, where they can access hundreds of practice analysis and performance reports. Should a practice require additional information, custom reports are also available upon request.

Additionally, PGM’s Reimbursement Specialists provide frequent practice performance reviews offering additional insight into practice financial operations.