Concise reporting keeps you informed of the status of your receivables. Sierra constantly evaluates the practice’s accounts receivable to determine current collection performance for each carrier type (e.g., Medicare, Medi-Cal, Medicaid, commercial insurance). Existing problems will be identified, and solutions devised and implemented. Collection standards will be established based upon our knowledge of each geographic locale and the expectations for each practice.
To assure the effective billing and collection of all accounts, specific procedures and services have been designed to enable us to meet performance standards that have placed Sierra in the forefront of Revenue Cycle Management.
Accurate coding is the foundation for proper claims payment. All of Sierra’s coders are Certified by the American Academy of Professional Coders, and Sierra ensures the coders certifications remain current and support their continuing education. Coding is a labor-intensive process that requires training and expertise. Sierra Health Services’ staff of expert coders, led by our management team that is certified by the American Academy of Professional Coders, will complete all claims on behalf of our clients. We periodically review all reports or charts to ensure that the CPT codes are consistent with published AMA guidelines and that the ICD-10 codes are appropriate. We train the appropriate personnel to ensure that all procedures are coded in compliance with the various governmental regulations.
The information required for proper billing of all services provided by the practice can be accepted by Sierra via electronic media or as hard copy forms. We work with all the major electronic health records (EHR) platforms and our proprietary billing application accepts data from each one of them. All electronic files will move through an intensive testing phase before they are put into live production. Sierra has a SQL-based tracking system that logs all batches from time of receipt through charge entry, eliminating the possibility of mis-queued batches. All charges are entered into the billing system and released within 48-hours of receipt.
Insurance Claim Submission
We generate all claims to the applicable payer via electronic data interchange (EDI) partner where available, a small portion of claims will submit on HCFA-1500 due to payer restrictions. Submissions will be made using the insurance data (group, policy, and insured’s numbers) and the claim submission address that has been verified through our matching program, or by phone call to the carrier, the insured’s employer, or the patient, as appropriate. Electronic billing edits are received, all denials are reviewed, worked and resubmitted within 24 hours.
Accounts Receivable Management
Sierra has developed a system to maximize revenue through timely billing and thorough accounts receivable follow up. Each client has an experienced manager and staff assigned to their account. Electronic billing edits are reviewed and corrected within 24 hours of submission. Denial reports are queued to the staff daily and completion reports reviewed by manager. All no response claims are also queued to be worked based on payer specific timelines. Claim closure reports are reviewed with staff to ensure actions taken are resulting in client revenue.
Fee Analysis and Review
We maximize your practice’s collections through the analysis of the fees that are currently charged for services by calculating a “practice conversion factor” based on the current fee schedule and the RBRVS units for the procedures/services being performed. We provide a recommended fee structure to assist you in making informed fee decisions. As part of our ongoing services, we periodically review your fee schedule to maintain its timeliness and sensitivity to your marketplace. Any changes to the initial fee schedule and all revisions will require your written approval. Using this data, we will be able to provide you with benchmarks for use with your contract negotiation.
Communications with Patients & Third-Party Carriers
Keeping patients informed about the status of their account is a top priority. All patient statements include the toll-free phone number to Sierra. Correspondence and phone contacts are documented in our system, changes in financial class are performed immediately, and the appropriate claim routine is initiated that day. We recognize the importance of public relations and professionalism when dealing with patients, insurance carriers, and staff. Our staff members are carefully trained in courteous phone etiquette and are not assigned to answer the phones until they have completed this training.
Third Party Follow-Up and Collections
We follow-up on all delinquent insurance and other third-party payments using internal past due reports. We render balance-due statements to patients following payment by the third-party carriers, and file secondary insurance claims directly with the carrier when such information is available.
Claims Appeals and Denial Management
Sierra maintains copies of the practice’s contractual arrangements with third-party payers. If, at time of posting the payment, an underpayment or inappropriate denial is identified, an appeal will be filed with the carrier seeking the additional reimbursement. We verify that the claim is properly paid before closing it out.
We produce and mail billing statements to patients or responsible parties on the day that the charge data and demographic data are matched up in our system. The billing statements can be customized to match the specific needs of your practice to facilitate prompt patient payment. Sierra always follows physician/practice specific self-pay collection and write-off policies.
Bad Debt Assignment & Recovery
It is Sierra’s policy to submit to the client a list of patient accounts which are deemed ready for bad debt collection prior to assigning them to an agency. This is solely at the discretion of the client, as we do have clients that allow us to make the final determination of whether an account goes to the collection agency. We work with several agencies and prefer the client choose their agency of preference.
All mail received by Sierra, at the address designated by our clients, is carefully controlled to ensure against loss. We have policies and procedures in place to ensure the amount received matches the amount posted and coincides with the amount deposited. All Sierra Health Services employees are fidelity bonded and deposits are made in accordance with the banking arrangements established by our clients.
Our Director of Credentialing has over 12 years of experience with physician and hospital credentialing, insurance credentialing and re-credentialing. We constantly analyze your existing, current, and future contracts to ensure that you are getting the best rates possible.
More information about our Credentialing services can be found here.
Business Advisory Services
We review, advise, and negotiate contracts with managed care and third-party payers, and present contracts for approval. We create and maintain a contract matrix for the group that will include the terms, contact people, and rates for all contracts. We work directly with your top executives in all areas of management of the group’s business practice, including acting as liaison with your outside professional services, including accounting and legal. We prepare for and attend the group’s quarterly and annual meeting as well as any scheduled business meetings. We provide support needed for the group’s board with regard to governance, leadership, and business management if requested.
Insurance Eligibility & Verification
Our proprietary billing software contains a real time insurance verification component to confirm a patient’s insurance prior to the claim being submitted, virtually eliminating insurance eligibility denials.
Manual Data Entry Services
As a sequential process, scanned or hard copies of the encounters received from the providers are coded by our qualified coding team and sent to the data entry department. The data entry team enters all information into the billing system within 24 hrs. Claims are created and submitted to the payers for payment processing accordingly. The team also enters any payment that needs to be posted manually.
Our cash posting staff is educated and experience in the disciplines for which they post payments. The staff understands each practice’s contracts and can discern between in-network and out-of-network allowables.
All physician contracted plans and corresponding rates are contained in our system and the payment received is compared to the contracted rate. Our software can automatically detect underpayments. If the payment does not match the contracted rate, the account is sent to our follow up department for review, rebilling, or appeal submission.