Payer Solutions

We are a pioneer in the claims process outsourcing arena, with proven demonstrable experience in insurance claims adjudication. We implement procedures and systems that are HIPAA complaint to process and adjudicate medical claims. Our customers are attracted to our relentless pursuit of quality (we offer 99%+ accuracy at claims level). Our processing timelines comply with CMS guidelines. Our claims adjudicators are trained in several industry-standard claims adjudication software programs, and can adapt to any claims adjudication system within a short period.

HIGHLIGHTS

• Verification of all keyed fields in case of claims that are not submitted electronically
• Determination of member eligibility and coverage
• Primary insurance verification
• Determination of timely filing limit of claims
• Confirmation of provider status (participating / non-participating).
• Checking authorization notes for instructions and applying authorization status to claims
• Identification of duplicate / corrected / interim / final submissions
• Determination of DRG
• Apply case-rate / per diem to services within the purview of the case-rate / per diem contract
• Determination of correct allowable
• Ensuring that co-pay, coinsurance, deductible and OOP are accurately calculated and applied as per the benefit plan
• Use of appropriate remark/adjustment codes
• Real time audits
• Customized reporting
  • Inventory Report
  • Quality report
  • Production report
  • Pend report
  • Skip Report

Credentialing is the process of obtaining, verifying, and evaluating qualification of a provider and determines whether an applicant is qualified to be a participating provider with the organization.

We are happy to aid provider groups as well as clients with a complete range of credentialing services through a time-tested technique that ensures that organizational providers are compliant with state and regulatory bodies before directing membership to these facilities.

Proper credentialing requires a watchful eye for total and stringent compliance with applicable standards. It also requires that applicants are evaluated in the right manner and their competencies are measured accurately. For this, a number of resources are consulted such as the social, academic and professional history of the applicant, peer and expert reviews, end-user reviews on the quality of the applicant’s services, and more.

We are fully equipped to take care of all these requirements quickly and efficiently. We approach the subject in an organized and systematic manner. The key steps in our credentialing process are as follows:

HIGHLIGHTS

• Full range of credentialing services
• Re-credentialing after every 3 years
• Regular update of provider data in credentialing and claims systems
• Generation of all pertinent reports like
  • HSD Report
  • Physician and Facility Reports
  • Weekly ADD/TERM report
  • Delegated credentialing report
  • Group/taxonomy etc. specific ad-hoc reports

We work with a full team of credentialing veterans who strictly abide by the standards and guidelines set within Medicare Managed Care Manual and National Committee for Quality Assurance (NCQA). So, why look anywhere else?

The Billing and Collection team provides customized and decisive solutions to Medicare and Medicaid HMOs, Commercial Insurance plans as well as PBMs, enabling them to achieve sustainable results. Our certified public accountants and financial analysts manage each process, using our robust data warehouse and state-of-art technology.

We are fully equipped and well-positioned to cater successfully to all the needs of our clients, providing them with sound, full-cycle billing and collection solutions. And all of this in a surprisingly cost-effective manner.

HIGHLIGHTS

Our Billing and Collection services include:

• Data Preparation and Entry
• Accounts Payable and Receivable
• Premium Billing
• Payment Tracking/Logging and Member Premium Reconciliation
• Plan to Plan Reconciliation
• Risk Management
• Report Generation, including DOI (Department of Insurance) Reporting, Cash Flow Statement, Segmental Report etc.
• Risk Sharing and Yearly CMS Payment Reconciliation

Utilization Management is the evaluation of the appropriateness and medical need of health care services, procedures and facilities, according to preset criteria or guidelines, and also under the provisions of an applicable health benefits plan. It is a critical and core component of the healthcare system in the US and requires professional expertise to a very high extent.

We specialize in providing our clients with a full range of Utilization Management services for Part A, B & D. Trust our accurate and timely reports, strict adherence to UM codes, efficient evaluation by qualified medical professionals and proven expertise to bring you robust and reliable Utilization Management solutions.

If cost-effective Utilization Management services are on your mind, look no further than here. Contact us today!

HIGHLIGHTS

• Dedicated team comprising physicians and pharmacists
• Medical transcription of clinical notes to aid in decision making in client specific systems
• Collection of additional clinical information from physician’s office
• Final decision made by qualified physicians and nurses in the US
• Reducing the standard procedure turnover time from CMS mandated 30 days to 7 days for Part A & B Utilization Management and from 72 hours to 48 hours for Part D Utilization Management
• Expedited procedure to determine authorization within 24-36 hours
• Standardized process and effective application of appropriate tools before rendering any decision
• Specialized clinical customer support 24×7 Help Desk