Healthcare BPO

Revenue Cycle (RCM) Complete

Comprehensive management of a healthcare organization’s financial cycle—from the moment a patient schedules an appointment until the account is settled. This encompasses all processes both preceding and following patient care.

WHAT’S INCLUDED:

PRE-VISIT: Verification of Benefits (VOB)—confirming active coverage; Demographic Verification to prevent claim denials caused by incorrect patient data.

PRIOR AUTHORIZATION: Liaison with the insurance carrier; submission of clinical doc.; recording of the authorization number and validity period within the EHR.

CODING: Accurate assignment of ICD-10, CPT, and modifiers based on physician notes; verification against NCCI edits.

CLAIM SUBMISSION: Submission of primary claims and secondary claims (in cases of dual coverage); coordination of benefits.

PAYMENT POSTING: Application of insurance carrier EOBs; identification of underpayments; request for payment adjustments where applicable.

DENIAL MANAGEMENT: Categorization of claim denials; formal appeals process, including the submission of a physician’s letter when necessary.

PATIENT BILLING: Issuance of patient statements; management of payment plans; automated reminders at 15, 30, and 45-day intervals; implementation of a respectful and HIPAA-compliant collections protocol.

EXECUTIVE REPORTING: Monthly dashboard featuring a P&L analysis of the revenue cycle, cash flow projections, industry benchmarking, and recommendations for operational improvement.

Medical Billings & Coding

The process of transforming rendered medical services into coded claims that are submitted to insurance carriers to obtain reimbursement.

WHAT’S INCLUDED:

MONTHLY REPORTING: Key metrics reported include Collection Rate, Denial Rate, Days in AR, Top Denial Reasons, and Identified Underpayments.

REVIEW: The physician generates clinical notes within the EHR, and MG Services accesses them using read-only credentials.

CODING: The coder assigns ICD-10 (diagnosis), CPT (procedure), and HCPCS (equipment) codes. All supporting documentation is reviewed.

VERIFICATION: Patient insurance eligibility is validated in real-time prior to submission.

PREPARATION and SUBMISSION: The electronic claim is submitted. The clearinghouse validates the format and transmits it to the insurance carrier.

CLAIMS STATUS MONITORING: Statuses tracked include Accepted, In Process, and Rejected. A root-cause analysis is performed for every rejection.

DENIED CLAIMS: Correction of the specific error + submission of additional documentation + resubmission within the designated appeal timeframe.

PAYMENT POSTING: Insurance carrier and patient payments are applied to the system. Underpayments are identified, and patients are billed for outstanding balances.

AR AGING FOLLOW-UP: Insurance carriers are contacted regarding claims that have gone unanswered for more than 30 days. Issues are escalated if not resolved within 60 days.

Prior Authorization Management

The process of obtaining prior approval from an insurer before a provider renders certain services. Without this authorization, the provider may be unable to bill for the services.

WHAT’S INCLUDED:

WEEKLY CLIENT REPORTING: Status updates on pending, approved, denied, and appealed authorizations, along with approval rates broken down by insurer and service type.

IDENTIFICATION: Our analyst determines whether authorization is required by consulting the plan’s benefits guide or by calling the insurer’s pre-authorization hotline.

DOCUMENTATION GATHERING: Collection of all supporting clinical documentation, progress notes, prior test results, medical history, and other relevant records.

AUTHORIZATION REQUEST SUBMISSION: Submission via the insurer’s online portal or secure fax; assignment of a tracking number.

FOLLOW-UP: Daily verification of pending requests; escalation for urgent review if the scheduled appointment is imminent (within 72 hours).

DENIAL: If authorization is denied, drafting of a first-level appeal letter featuring medical arguments grounded in clinical guidelines.

IF THE FIRST-LEVEL APPEAL IS REJECTED: Arrangement of a «peer-to-peer» review between the treating physician and the insurer’s medical reviewer.

RECORD-KEEPING: Recording of the approved authorization number, validity dates, and usage limits within the EHR and MG’s internal tracking system.

Patient Scheduling & Intake

Centralized management of the medical schedule and the new patient intake process. Serves as the patient’s first point of contact with the practice.

WHAT’S INCLUDED:

WEEKLY REPORTING: Metrics covering no-show rates, last-minute cancellations, average wait times for initial appointments, and reasons for rescheduling.

CONFIGURATION: Setup of the client’s scheduling system, including availability trees, appointment types, and duration settings per provider.

HANDLING of INBOUND CALLS and ONLINE REQUESTS: Identity verification, determination of consultation type, insurance verification, and scheduling based on availability and the requested provider.

REAL-TIME ELIGIBILITY VERIFICATION: Performed at the time of scheduling. Proactive communication with the patient regarding copays and specific requirements.

APPOINTMENT CONFIRMATION (48 hours prior): Conducted via multiple channels. Confirmation calls are made for high-priority appointments or surgical procedures.

CANCELLATION MANAGEMENT: Immediate offering of available time slots to patients on the waitlist to minimize gaps in the schedule.

NEW PATIENT INTAKE: Digital distribution of intake forms. Verification and uploading of demographic data, basic medical history, and insurance information into the EHR.

AUTHORIZATION MANAGEMENT: Oversight of information review and digital consent signing. Provision of pre-consultation instructions to the patient.

Credentialing & Provider Enrollment

Verification and documentation of medical provider credentials with insurance payers, hospitals, and regulatory bodies. Without active credentials, the provider cannot bill insurance companies.

WHAT’S INCLUDED:

CREDENTIAL STATUS DASHBOARD: Displaying the status of all credentials—active, nearing expiration, in process, or denied. Automated alerts sent to the client 90, 60, and 30 days prior to expiration.

INITIAL CREDENTIALING: Collection of documents—medical license, DEA registration, NPI, board certifications, malpractice insurance certificate, and updated CV. Primary source verification of each credential with the original issuing authority: state medical board, NPDB, AMA, and specialty board.

PAYER ENROLLMENT: Completion of network participation applications for Medicare, Medicaid, BCBS, United, Aetna, Cigna, and Humana. Active follow-up throughout the process.

CAQH PROFILE: Creation and maintenance of the provider’s CAQH ProView profile. Quarterly attestation. Sharing access with participating insurance payers.

HOSPITAL PRIVILEGES: If the provider holds hospital privileges, management of biennial renewals and new applications with the hospital’s credentialing committee.

RE-CREDENTIALING: Tracking of expiration dates for licenses, DEA registrations, and malpractice insurance. Initiation of the renewal process 6 months prior to expiration.

Healthcare IT Help Desk (EHR)

L1 and L2 technical support for users of EHR/EMR systems and clinical applications. Enables physicians and nurses to focus on patient care without technological interruptions.

WHAT’S INCLUDED:

TRAINING FOR NEW CLIENT USERS: Onboarding sessions, quick-reference PDF guides, and video tutorials for the client’s knowledge base.

LEVEL 1: Access and authentication issues, password resets, basic EHR navigation, telehealth configuration, report printing, device activation.

LEVEL 2: Configuration of workflows, order sets, and clinical templates; diagnosis mapping; user permission adjustments; integrations between EHR modules; synchronization errors with labs or pharmacies.

TICKET MANAGEMENT: Categorization as P1 (Critical: System Down) / P2 (High: Functionality Blocked) / P3 (Normal: Inquiry or Enhancement).

DOCUMENTATION: Recording of all incidents in a knowledge base. Identification of recurring issues to propose permanent improvements.

SECURE REMOTE ACCESS: To the user’s device. Credentials are never stored; sessions are audited.

COORDINATION with EHR VENDOR: For issues escalated to L3 (system bugs, failed updates).