PCG has expertise in the creation, implementation, and management of Administrative Services Organizations (ASO). This service provides the first line of defense between a provider and fiscal intermediaries to ensure that submitted claims meet federal, state, and local Medicaid claiming policies. We partner with state Medicaid programs to provide oversight and management of specific healthcare services and/or beneficiaries, such as school-based healthcare.
Due to the need to be fiscally responsible and to ensure compliance that can withstand external CMS audits, program oversight is imperative. Program oversight provides a level of comfort for both the agency and the healthcare finance department that claims are clean and disallowances are reduced. PCG’s Revenue Cycle team is experienced in all phases of ASO functions, from documenting regulatory requirements, to providing and implementing automated systems to process and evaluate claims, to providing independent oversight of operational claiming processes.
PCG performs the following services:
- Creating and supporting a clearing house claiming database for each program or service
- Importing patient eligibility, provider data, and other regulatory required data to meet claim validation needs
- Performing front-end validation of claims data prior to claim generation
- Generating and submitting claims
- Research denials prior to claim submission to the fiscal intermediary to determine corrections, thus reducing denials
- Claim Management
- Posting and reconciling payments
- Working with providers to resolve workable denials and rejections
- Training providers on industry best practices and payer rules
- Creating standardized and ad-hoc reports
- Creating program-specific audit processes based on regulatory requirements
- PCG has a web-based application that can be customized to produce agency-specific medical record documentation requirements to review medical records for compliance
- Our application produces a pass, fail, deficient results spreadsheet, allowing Healthcare Finance and agency stakeholders the data needed to improve documentation best practices
- Audits can be used to support internal compliance plans and to support auditing and monitoring practices
- Audits are performed by Certified Coders/Auditors and support the need for third-party disinterested medical record assessments
- Revenue Cycle and Regulatory Consulting
Areas supported by PCG include:
- Support with external audit requirements, results, and rebuttals
- Annual review of service codes (CPT) and diagnostic codes
- Assistance with and training on documentation requirements for new codes
- Support with medical record forms review to ensure compliance based on federal, state, and local requirements