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     Payer

• Payer organizations worldwide are focused on managing the gap between funding and medical costs, often in the context of a changing regulatory environment. Effective solutions to these challenges need to be tailored to local health-care systems, and payer organizations must find the best ways to influence the evolution of their health care systems.

  Healthcare expenditures are a significant component of the US economy and are expected to grow to 4.4 trillion by 2018 from exceeding $2.6 trillion in 2012. Cost of administration of healthcare being a major component of this expenditure.

  Pinnacle recognizes the need of reducing these expenses especially in the current economy and offers outsourcing model to alleviate administrative challenges and free up resources to focus on your core business needs.

• Source: http://www.pbs.org/newshour/rundown/2012/10/seven-factors-driving-your-health-care-costs.html
  A Deeper Look At Our Payer Services
  
  Policy Administration
    Enrollment
        1. Enrollment Application Processing
        2. Data Validation
        3. Issuance of Plan Document
        4. Issuance of Certificate of Coverage
  
    Policy Maintenance
        1. Demographic change request processing
        2. Policy Renewal Processing
        3. Policy Termination Request Processing
        4. Policy Change Request Processing
        5. Refund Request Processing

  Billing
    Premium Invoicing
        1. Premium Billing
        2. Premium Reminder Processing
        3. Follow Up
        4. Premium Receipts Processing
        5. Premium Accounting
        6. Report Generation
  
    Policy Reconciliation's
        1. Premium Reconciliation with Bank statements
        2. Premium Reconciliation's with Employer statement
        3. Report Generation for Regulatory and Statutory Compliance Requirements

  Claims Management
    Mailroom & Imaging
        1. Paper Claims Receipt (UB 92, UB 04 CMS 1500, ADA)
        2. Sorting / Prepping
        3. Imaging
        4. OCR / ICR
  
    Pre-adjudication
        1. OCR Data Capture Validation
        2. Claims Data Entry (Hand written Claims)
        3. Provider Eligibility Validation
        4. Edit Resolution
        5. Member Eligibility Verification
  
    Adjudication
        1. Coding Verification
         2. Edit Resolution (Medical, Facility and Dental Claims)
         3. Claims Re-pricing
         4. EOB Processing
         5. Member / Provider Communication Processing
         6. Aged Claims Reporting
         7. Claims Quality Audit
  
    Collections
        1. Over-Payment / Under-Payment Analysis
        2. Root Cause Analysis
        3. Provider / Member Follow Up and Recovery

  Provider Network Management
    Provider Credentialing
        1. Collation of credentialing data like education,  peer references, training, malpractice
        history, etc.
        2. Verification of credentials
        3. New Provider Profile Upload
        4. Ongoing credentialing Support
  
    Provider Contract Management
        1. New Contract Uploading
        2. Ongoing Contract Maintenance
        3. Contract Renewal Support
        4. Contract Performance Analysis

  Source: http://www.dtscinc.com/bpo_hc_payor.htm

   

     Provider Service

• Timely billing is an integral part of an effective revenue cycle. Ensuring that all registration and data entry errors are identified and tracked prior to claim submission is one of many billing solutions that Pinnacle has implemented in their billing process. Once a bill is submitted, we incorporate timely follow-up techniques to ensure sustainable, long term cash improvements

  •    Minimize billing delays
  •    Strong follow-up processes
  •    Workflow management reporting tools
  •    Sustainable , long term cash improvement

  A Deeper Look At Our Provider Services

  Medical Billing
  1. Demographics Entry
  2. Charge Entry
  3. Coding
  4. Claims submission
  5. Cash posting
  6. Denials Management
  7. Account Receivables Analysis
  8. Account Receivables follow up
  
  

  Hospital Billing
  1. Demographics Entry
  2. Charge Entry
  3. Coding
  4. Claims submission
  5. Cash posting
  6. Denials Management
  7. Account Receivables Analysis
  8. Account Receivables follow up
  
  

  Post-Discharge and Post-Injury Billing
  1. Indexing
  2. Invoice Processing
  3. Accounts Receivables
  4. Claims submission
  5. Cash posting
  6. Denials Management
  7. Account Receivables Analysis
  8. Account Receivables follow up
  
  

  Accounts Payables
  1. Accounts Payables Analysis
  2. Vendor Payments
  3. Dispute Management
  4. Vendor Mapping
  5. Vendor Management
  6. Customer Service
  
  

  Clearing House
  1. Explanation of Benefit Processing
  2. Eligibility Verification
  

  Source: http://www.technosoftcorp.com/bpo/provider_rcs.htm

   

     Pharmacy Benefit Management Service

• Pharmacy Benefit Management companies are primarily responsible for processing and paying prescription drug claims. They also are responsible for developing and maintaining the formulary, contracting with pharmacies, and negotiating discounts and rebates with drug manufacturers. 

  When it comes to specialized PBM services, we are not far behind. In fact, Pinnacle is well-acquainted with the major industrial challenges that PBMs encounter. We know that there is an ardent need for extensive and organized documentation support as well as improvement of prescription medication outcomes and maintenance of rationality of prescriptions. Understanding the  gap, we offer customized services to help our clients make the best use of our services.

  A Deeper Look At Our Provider Services

  1. Member Enrollment
  2. Member Enrollment Fulfillment
  3. Doctor Credentialing
  4. Mail Order Pharmacy services
  

  Source: http://www.technosoftcorp.com/bpo/provider_rcs.htm