Mid Revenue Cycle Services

Medical Billing and Claims Submission

The mid-cycle phase transforms clinical documentation into accurate claims ready for payer submission. This technical phase requires coding expertise, charge capture precision, and thorough quality assurance to maximize clean claim rates.

Medical Coding Services

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Service Overview:

Professional medical coding translates clinical documentation into standardized diagnostic and procedural codes. Coding accuracy directly determines reimbursement levels, compliance status, and denial rates. Our certified coding specialists ensure optimal code assignment across all specialties.

Coding Services:

  • ICD-10-CM diagnostic coding with appropriate specificity
  • CPT and HCPCS Level II procedural coding
  • Evaluation and Management (E/M) level selection following current guidelines
  • Modifier application for special circumstances and billing rules
  • Code linkage validation for medical necessity support
  • Principal and secondary diagnosis sequencing
  • Present on admission (POA) indicator assignment for inpatient claims
  • DRG assignment and validation for hospital services
  • Specialty-specific coding expertise across 50+ medical specialties

Coder Qualifications:

  • Certified Professional Coders (CPC) credentialed through AAPC
  • Certified Coding Specialists (CCS) for hospital coding
  • Specialty-specific certifications for complex areas (cardiology, orthopedics, oncology)
  • Continuous education on coding updates and guideline changes
  • Regular competency assessments and quality audits
  • Experience with multiple EHR and practice management systems

Quality Assurance Program:

  • Random sampling audits measuring accuracy rates
  • Targeted audits for high-dollar or high-risk procedures
  • Feedback loops providing education on identified issues
  • Benchmark comparisons against industry accuracy standards
  • Compliance monitoring for proper documentation requirements
  • Quarterly coding education sessions on emerging topics

Technology Enablement:

  • Computer-assisted coding (CAC) tools for efficiency gains
  • Natural language processing to analyze clinical notes
  • Real-time coding validation and error prevention
  • Integration with clinical documentation improvement programs
  • Analytics identifying coding patterns and optimization opportunities

Charge Entry and Charge Capture

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Service Overview:

Comprehensive charge capture ensures that all billable services are identified, documented, and entered for billing. Charge capture leakage—missed charges for services rendered—represents one of the most significant sources of preventable revenue loss in healthcare.

Charge Entry Services:

  • Superbill and encounter form processing
  • Charge data extraction from multiple source documents
  • Electronic charge capture from integrated EHR systems
  • Service date, provider, and place of service validation
  • Procedure code and quantity verification
  • Diagnosis code linkage for each line item
  • Modifier assignment per billing requirements
  • Fee schedule application and charge amount calculation
  • Duplicate charge detection and prevention

Charge Capture Auditing:

  • Pre-bill audits comparing charges to clinical documentation
  • Post-service reviews identifying undocumented services
  • Operating room and procedure suite charge reconciliation
  • Implant and supply charge validation against inventory logs
  • Professional fee capture audits for hospital-based physicians
  • Emergency department charge capture reviews
  • Ancillary service charge validation (lab, radiology, therapy)
  • Benchmarking of charges per encounter against specialty norms

Revenue Recovery Activities:

  • Retrospective charge reviews identifying missed opportunities
  • Late charge submission within payer timely filing limits
  • Provider education on complete service documentation
  • Workflow improvement recommendations to prevent future leakage
  • Quantification of recovered revenue and capture rate improvements

Clinical Documentation Improvement (CDI)

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Service Overview:

Clinical documentation improvement ensures that provider documentation accurately reflects the complexity, severity, and resources involved in patient care. Quality documentation supports accurate coding, appropriate reimbursement, and meaningful quality reporting while protecting against compliance risks.

CDI Services:

  • Concurrent documentation review during patient stay or shortly after encounter
  • Query generation for clarification of ambiguous or incomplete documentation
  • Physician education on documentation best practices and requirements
  • Diagnosis specificity improvement (laterality, stage, acuity)
  • Complication and comorbidity (CC/MCC) capture for proper case mix
  • Clinical validation of diagnosis codes against documented evidence
  • Documentation linking treatments to documented conditions
  • Risk adjustment factor (RAF) optimization for value-based contracts
  • Quality measure documentation ensuring reportable elements are captured

CDI Staffing Models:

  • Remote CDI specialists reviewing records electronically
  • On-site CDI presence for complex inpatient environments
  • Hybrid models combining remote efficiency with on-site collaboration
  • Specialty-focused CDI for high-complexity service lines
  • Flexible staffing scaled to organizational volume and needs

Impact Measurement:

  • Case mix index (CMI) improvement tracking
  • Query response rates and physician engagement metrics
  • Documentation quality scores and improvement trends
  • Reimbursement impact from improved documentation specificity
  • Denial reduction attributable to clearer documentation
  • Quality measure performance improvements
  • Compliance risk mitigation through proper documentation

Claims Scrubbing

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Service Overview:

Claims scrubbing applies automated and manual edits to identify and correct errors before payer submission. Clean claims—those submitted correctly the first time—are paid significantly faster than claims requiring payer follow-up or resubmission.

Scrubbing Services:

  • Automated edit checking using comprehensive rule engines
  • Payer-specific edit application based on individual payer requirements
  • National Correct Coding Initiative (NCCI) edits validation
  • Medical necessity screening using local and national coverage determinations
  • Duplicate claim detection preventing multiple submissions
  • Demographic data validation against payer eligibility files
  • Authorization number verification and attachment
  • Fee schedule validation ensuring correct charge amounts
  • Place of service and type of service consistency checking

Error Resolution Workflow:

  • Suspended claims routing to appropriate resolution queues
  • Coder review for coding-related errors
  • Billing specialist review for demographic or administrative errors
  • Provider query processes for clinical clarification needs
  • Authorization team escalation for missing approvals
  • Systematic error tracking identifying root causes
  • Process improvements addressing recurring error patterns

Clean Claim Performance:

  • Clean claim rate targets of 95% or higher
  • First-pass acceptance rate monitoring by payer
  • Denial prevention through pre-submission error correction
  • Accelerated payment timelines from reduced rework
  • Reduced administrative burden from claim corrections

Payment Posting and Cash Reconciliation

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Service Overview:

Accurate payment posting updates patient account balances while providing critical data on payer performance, denial trends, and revenue cycle health. Thorough cash reconciliation ensures all payments are properly accounted for and applied.

Payment Posting Services:

  • Insurance payment posting from ERA files and paper EOBs
  • Patient payment posting from multiple collection channels
  • Line-item payment allocation to specific service charges
  • Contractual adjustment calculation and application
  • Denial posting with appropriate action codes
  • Secondary insurance billing for remaining balances
  • Patient balance transfers for patient responsibility amounts
  • Refund identification for overpayments
  • Credit balance resolution and processing

Manual Payment Processing:

  • Paper EOB data entry with dual verification
  • Payment receipt imaging and document management
  • Payment correspondence review and appropriate action
  • Check deposit processing and bank reconciliation
  • Lock box payment processing for high-volume organizations
  • Patient portal payment reconciliation
  • Point-of-service payment integration

Cash Reconciliation:

  • Daily batch balancing of posted payments
  • Bank deposit reconciliation to posted amounts
  • Unidentified payment research and application
  • Payment variance investigation and resolution
  • Month-end financial close support
  • Accounts receivable aging accuracy validation
  • Revenue reporting and financial statement preparation support

Data Analytics:

  • Payment trend analysis by payer and service line
  • Contractual adjustment variance monitoring
  • Denial rate tracking and trending
  • Days in accounts receivable measurement
  • Collection rate calculation and benchmarking
  • Payer performance scorecards

Claims Submission and EDI Management

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Service Overview:

Timely claim submission initiates the payment process. Electronic Data Interchange (EDI) streamlines claim transmission while enabling real-time status tracking and automated remittance processing.

Submission Services:

  • Electronic claim generation in HIPAA-compliant 837 format
  • Clearinghouse connectivity for multi-payer claim routing
  • Direct payer portal submissions when EDI unavailable
  • Paper claim generation and mailing for exceptional situations
  • Attachment handling for claims requiring additional documentation
  • Timely filing monitoring ensuring submission within payer deadlines
  • Submission tracking and acknowledgment monitoring
  • Rejection management and rapid resubmission

EDI Transaction Management:

  • 837 Professional and Institutional claim submissions
  • 270/271 Eligibility inquiry and response processing
  • 276/277 Claim status inquiry and response handling
  • 835 Electronic Remittance Advice (ERA) receipt and processing
  • 999 Implementation Acknowledgment tracking
  • TA1 Interchange Acknowledgment monitoring
  • Trading partner enrollment and connectivity maintenance
  • Clearinghouse relationship management and optimization

Performance Monitoring:

  • Daily submission volume tracking by payer
  • Clearinghouse acceptance rate monitoring
  • Days in claims not submitted (DCNS) measurement
  • Average days to submission from service date
  • Rejection rate analysis and trending
  • Payer response time tracking

Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT) Processing

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Service Overview:

Electronic payment processing accelerates cash posting and reduces manual effort. ERA files provide detailed payment information enabling automated posting and comprehensive payment analysis.

ERA Processing:

  • 835 ERA file receipt from payers and clearinghouses
  • Automated payment posting to patient accounts
  • Exception handling for transactions requiring manual review
  • Adjustment code interpretation and proper application
  • Remark code analysis for additional payer instructions
  • Denial identification and routing to management queues
  • Correspondence and refund request identification
  • Secondary billing triggers for remaining balances

EFT Management:

  • Electronic funds transfer enrollment with all major payers
  • Bank account management and security protocols
  • EFT and ERA matching for complete payment reconciliation
  • Wire transfer and ACH deposit tracking
  • Virtual credit card processing when applicable
  • Daily deposit reconciliation and variance investigation

Cash Acceleration Benefits:

  • Same-day or next-day cash availability from electronic payments
  • Reduced mail delays in check receipt
  • Automatic posting eliminates manual entry lag
  • Improved cash flow predictability
  • Reduced bank fees and check processing costs
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