Laboratory Coding
According to the AMA, the average Laboratory submits more than 50% of its claims with incorrect codes. For laboratories the issue is exacerbated due to advances in molecular laboratory tests outpacing the establishment of CPT/PLA codes. Use of “unspecified “codes must be accompanied by accurate descriptions, “Z” codes and/or documentation. 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 demographics data entry/upload
Patient demographics and accession charges are collected 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 a Laboratory Information System (LIS), patient demographics and accession charge data can be electronically transferred via HL7 integration, in real-time, to our practice management system.
Claims 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. PGM's software performs thousands of checks, including CPT/ICD-10 validations, modifier checks, demographic comparisons and payer-specific edits.
The claims review process ensures that laboratory 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 clearinghouse. Edits and errors are relayed back to PGM for correction prior to submission to the payer.
Payment Posting
Payments are received either hard copy or via electronic fundstransfer (EFTs). The corresponding explanation of benefits (EOBs) are received hard copy or as an electronic remittance advices (ERA) which PGM retrieves directly. PGM clients are given the option to continue to receive payment at the laboratory 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 misadjudicated claims.
Once an unpaid or misadjudicated 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
We work directly with laboratories to customize a patient billing profile, and perform all patient billing functions on behalf of the laboratory.
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 laboratory to structure a patient payment plan or transition the balance to a third-party collection agency for resolution.
Reporting
With PGM's laboratory billing software, you get clearer, real-time visibility into claim status and laboratory operations. Labs are provided access to our cloud based revenue cycle management software, where they can view and manipulate data on nearly any level. Data can be filtered and sorted on nearly any field or data point. From accession reporting to sales force performance, PGM’s reporting engine is focused on increasing your bottom line and giving revenue control back to your business.
