PCMG Process- HOW IT WORKS
1. CLIENT IS REGISTERED INTO PCMG SYSTEM
A. Client’s current forms & processes are reviewed/updated for efficiency & HIPAA compliance
B. Client is loaded into PCMG system, staff is trained, remittance addresses are updated
a. Access to PCMG Scheduler (if desired)
b. Access to PCMG PM (Practice Management System)
c. Access to Ebridge EDS (Electronic Document Storage System)
C. If chosen, Credentialing Service occurs concurrently
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
D. (Any payments that are received in-house initially are forwarded to PCMG)
3. PCMG PROCESS
1. DATA ENTRY & BILLING
A. All received data for the patient visit is scrubbed for completeness and correct coding prior to data entry occurring
B. 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
C. All complete data is entered
D. Data is again scrubbed prior to being billed for applicable CCI/LCD/& other edits
E. All data is billed electronically (*except payors that cannot receive electronic claims- these are billed on paper)
1. WC, NF, claims that need reports
2. RECEIPTS
A. All receipts are received at the lockbox or via ERA remittance. Any that are received at the client’s office
should be forwarded to PCMG
B. Receipts are divided into two batches- denials/pends and payments
C. Denials/Pends are given to denials management dept for immediate work
D. Receipts are posted and applied and reviewed for complete & accurate payment
1. Adherence to fee schedule (if an MCO agreement exists)
2. Partial payments are reviewed and given to denial Mgmt dept for appeals
3. DENIALS MANAGEMENT (Follow-Up and APPEALS Process)
A. All incorrectly paid or denied receipts (that can be appealed) are appealed according to standard templates and procedures set-up by PCMG
1. 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
2. Standardized Phone & Internet appeal process
3. 2nd level appeals
4. Complaint Process- State Insurance Commissioner & ERISA
B. FU (Follow-Up) occurs on all claims > 30days
1. Tickler system for FU and Appeals
2. Standardized appeal templates and procedures are used as specified above
4. PATIENT STATEMENTS and COLLECTIONS
A. Statements are mailed to patients on the 7th of every month
B. 3x statement cycle (90 days)
C. All patient phone calls are answered by PCMG
D. Last statement- collection letter & phone call
E. Collection Manager reviews accounts according to guidelines setup by client
F. CD report (Collection Decision Report) gets sent to client on 20th of every month for collection decision
5. INVOICE and REPORTING
A. Client is invoiced, payment is due via ACH on 15th of month
B. Client receives desired reports for financial analysis
6. MEETINGS
A. On-going
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