HEALTH SYSTEM SOLUTIONS

Front-end patient services that are used prior to the delivery of clinical services, set the stage for full and prompt payments after care is provided.  The patient access department serves a critical role in provider organizations as it interacts with every patient through the registration, insurance verification and cash collection process.  Due to increased pressure to enhance patient experience, healthcare organizations need to improve their patient access services by employing best practice workflows through the implementation of technology, processes and highly trained personnel.

Patient access services are enhanced using our trained staff who use best practices and technology for the following functions:

• Scheduling – Streamlining scheduling processes to ensure patient convenience and provider readiness.
• Insurance Verification – Verifying that the patient is covered helps ensure clean claims are sent to insurers.
• Pre-Authorization/Authorization – Ensuring patients are cleared for services they are scheduled to receive assures reimbursement for those clinical services.
• Financial Assistance/Eligibility – Utilizing compassionate patient advocates and an automated tool that provides real-time eligibility verification, our staff assist in identifying uninsured or underinsured patients and providing them with options for financial help such as Medicaid enrollment or disability applications, state and county programs, among others safeguards payments for services rendered.  
• Patient Liability/POS Collection – Streamlining account resolution, establishing patient liability expectations, and automating scoring for charity and the likelihood of payment allow for collections that are due from the patient.
• Pre-Registration/Registration – Registering or pre-registering patients for services being provided allows for efficiencies in the process and helps in the collection of robust data set of payment and patient information.  Such data can later be used for both clinical and financial purposes and helps increase patient satisfaction.

  - Self Service Pre-Registration - Allowing patients to get an estimate of charges and patient out of pocket amounts for scheduled procedures, helps patients make better decisions about their healthcare.
  - Text/Email Appointment Reminders – Helping in the reduction of “no-show’s” for appointments.
  - Concierge Check-In – Allowing for patients who pre-register with the self-service portal to access concierge check-in.

These functions, when done correctly can efficiently facilitate a clean claim and prompt payment from payers.

The middle section of the revenue cycle should be designed to ensure that the data collected and used for payments is robust, correct, and up-to-date. The Health Information Management (HIM) department serves a critical role in provider organizations in the collection and retention of clinical and financial data.  As healthcare organizations grow with an emphasis on performance excellence and business strategy, accurate coding and clinical documentation integrity are paramount to an organization’s financial success and longevity. Our credentialed clinical coders and certified management staff enable our clients to receive accurate reimbursement.

HIM services are enhanced using our trained staff who use best practices and technology for the following functions:

• Release of Information – Streamlining the approach for the disclosure of patient information with an emphasis on privacy and security.
• Transcription – Capturing and transforming physician dictation into meaningful, actionable information with improved turnaround time.
• Coding – Coding is the cornerstone of any HIM service. We offer U.S.-based and offshore coders who provide coding services to inpatient, outpatient care facilities, physician offices, and clinics, etc. Our coding services also include quality assurance measures to ensure coder accuracy and efficiency.
• Archiving – Enhancing processes for the digital storage of legacy and current data so it is compatible and retrievable by any electronic medical record (EMR).
• Chart Preparation – Preparing charts, often by providing scanning and other digitization methods, for billing and clinical purposes.

These functions, when done correctly can efficiently facilitate full and correct payment from payers.

In conjunction with HIM, revenue integrity operates in the middle section of the revenue cycle and is used to ensure that the data used for payments is robust and up-to-date. The revenue integrity department serves a critical role in provider organizations for the accurate documentation of clinical services, translating these into reimbursable offerings.  We design and implement processes to monitor revenue and identify, correct, and optimize the processes and systems that lead to lost revenue.

Revenue integrity services are enhanced using our trained staff who use best practices and technology for the following functions:

• Clinical Documentation Improvement (CDI) – Supporting providers with tools and innovative educational programs that foster an environment that promotes clinician-coder collaboration and improved documentation accuracy and clarity. Complete and accurate documentation helps to better support quality reviews, audits, accurate reimbursement, pay-for-performance programs, quality indicator expansion and value-based purchasing.
• Charge Description Master (CDM) maintenance – Streamlining processes for the maintenance and updating prices of services provided ensures that services provided are categorized and reimbursed at levels they should be. Our process includes subject matter experts and advanced benchmarking and workflow technology that has a robust design and unique user interface designed to save time and facilitate accurate and comprehensive charge-master content that can be used within all billing systems. The use of advanced cloud-based technology allows support of a maintenance process that is fully automated, engages clinical directors through automated workflow, continual charge analytics and ready access to peer pricing and other regulatory information tailored to the services performed in the clinical departments.
• Payment Variance – Integrating analysts experienced with managed care payers to evaluate contracts and claims data with proprietary software to accelerate the audit process and quickly improve claim recoveries.
• Charge Audit – Offering a variety of revenue cycle audit services to assist clients in monitoring their charge practices, Guidehouse uses an intuitive, cloud-based technology platform that incorporates leading hospital charge practices, governmental regulatory guidelines, and predictive logic to identify missing charges from both itemized bills (pre-billed service review) and final bills (post-bill audit). Features of this technology include: 

  - Pre-bill analysis in addition to standard post-bill review
  - Proprietary, intuitive charge capture practice algorithms
  - Intelligent workflow capabilities
  - Immediate gross and net revenue impact

Charge capture technology helps determine where and why revenue is not being captured to implement processes that address the root cause. This gives clinical and finance leadership confidence that the health system is capturing the appropriate revenue for services rendered.

These functions, when done correctly can ensure that clinical services translate into financial compensation for providers and help prevent denials.

Back-end patient account resolution services guarantee full and prompt payment after care is provided.  The patient financial services (PFS) department serves a critical role in provider organizations to ensure the full and timely collection of payments. As healthcare providers look for ways to achieve the full potential of their revenue cycle, it is vital to increase collections and obtain timely and accurate reimbursement on every patient account. As a leading extended business office services provider, our accounts receivable management team members extend the capabilities of your business office to gain efficiencies and reduce accounts receivable.

PFS services are enhanced using our trained staff who use best practices and technology for the following functions:

• Billing – Streamlining billing processes to edit claims before being submitted to avoid rejection due to regulatory or payer specific rules and also manage the transmission and submission of claims.
• Insurance Follow Up – Using automated workflows to reduce manual tasks and expedite denial and account follow-up activities, we provide follow-ups for third party and self-pay accounts to receive full reimbursement for services provided.  

- Aged Accounts Receivables (A/R) – Our team members apply government and national payer experience for accurate and timely reimbursement and use analytics to provide summary and detail-level reports to complement a process of consistent and standardized follow-up for aged accounts
- Low-Balance A/R – For low-balance accounts, our team members use similar processes and technologies for consistent and standardized follow-up
- A/R System Conversion – We utilize technology-enhanced processes to efficiently resolve accounts receivable from the legacy system, enabling the healthcare organization to focus on the implementation and training efforts involved in deploying the new system. Our solution assists in achieving a faster sunset of the legacy system while maintaining cash flow and improving provider resource utilization

• Self-Pay Follow Up – Working with hospitals and physician practices, we automate account stratification while making sure we are sensitive to the patient experience, offering an effective and compassionate account resolution process.  As well as develop payment tools, such as payment plans and financing options to ensure full payment.  While using creating and using payment portals to streamline the payment process, among other services. Our full offering of the self-pay solution includes:

  - Patient segmentation
  - Insurance scrubs
  - Bankruptcy & deceased scrubs
  -Skip tracing
  -Predictive dialer
  - Payment plans
  - Single billing office (for hospital and physician billing)
  - Payment portal
  -Patient satisfaction surveys

• Payment Processing – Converting paper remittances to electronic 835 files by combining an affordable workforce with software tools ranging from optical character recognition, workflow and denials mapping, to daily deposit reconciliation, reason code cross walking and quality assurance reviews leads to convenient payment options and processing for patients and providers.
• Credit Balance – Using best in class processes to provide potential credits and refunds to patients (and insurers).
• Credentialing – Completing provider applications and agreements for new or relocated providers in hospitals and surgery centers, assist with insurance and payer credentialing and re-credentialing, as well as verifying and updating other registrations such as professional licenses, professional diploma, CV, residency and fellowship certificates, board certifications, DEA, CLIA, NPI, CAQH, ECFMG, and CME.  These services ensure that providers are eligible to provide care and get paid for it.

These functions, when done correctly can ensure the collection of payments from those that under obligation to reimburse for clinical care.