Revenue cycle management system

Our long-term partner, MedScope America Corporation, is a private company that provides Personal Emergency Response Systems (PERS). These alert devices are designed to ensure that at-risk patients can remain safe in the comfort of their homes. By enabling users to access immediate medical assistance, PERS products help decrease hospital readmissions and improve health outcomes.

The client faced challenges, including the absence of a sufficient system for claim processing and billing and fragmented or incomplete patient data. As a part of our collaboration with MedScope, we were asked to create a comprehensive and efficient solution to address these challenges.

Revenue cycle management includes the following operations:

1. Pre-authorization and eligibility checks

At this stage, all relevant information about patients—such as valid address, insurance policy status, coverage limit (if any), AMA and MCO IDs—along with PERS devices and service charges, is collected. Patients’ insurance coverage is validated and invoices are created in electronic or paper format following compliance standards. Claims are generated based on the invoices. This stage helps reduce claim denials and guarantee timely reimbursement.

2. Claim submission

The validated claims are submitted to insurance payers to request reimbursement. The claims are submitted in accordance with payer-specific requirements to minimize the risk of denials. Some claims pass through EZClaim-enabled clearinghouse validation to enhance accuracy.

3. Payment posting

The received payments are matched to claims, and the status of the corresponding invoices is updated. When an invoice is fully paid, it is settled. For overpayments, invoices are settled and deposits for the excess amount are created. In the case of a partial payment, a new invoice is created for the underpaid amount and resubmitted. Denials are handled through denial management.

4. Denial management

Insurance claims can be denied due to inefficient or inaccurate data. In this case, denials are analyzed, corrected, and resubmitted if necessary. This stage helps reduce the number of denials caused by missing or incorrect information.

Private customers go through the following procedure:

• Registering through the customer portal. Two-factor authentication through the Vonage SMS API enables secure management of users’ data and accounts.
• Creating a bank or credit card account by entering their personal data and information about the PERS device. Authorize.Net ensures data privacy and compliance with regulatory standards.
• Paying invoices for PERS services each month. In case of overpayments, deposits are created for customers. In case of underpayments, new invoices are issued. Customers can also dispute an invoice in case of errors or inaccuracies and receive a refund if the dispute is resolved.

The system we created offers our client optimized and consistent claim and invoice submission and processing while ensuring compliance with data security standards and regulations.

As our partnership with MedScope continues, our team offers support and assistance in improving the client’s software. For over 10 years, we’ve been helping MedScope’s in-house team enhance their processes and service delivery with new plug-ins, portals, and integrations.