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.

A Deeper Look At Our Payer Services

Policy Administration

Enrollment
Enrollment Application Processing
Data Validation
Issuance of Plan Document
Issuance of Certificate of Coverage

Policy Maintenance
Demographic change request processing
Policy Renewal Processing
Policy Termination Request Processing
Policy Change Request Processing
Refund Request Processing

Billing

Premium Invoicing
Premium Billing
Premium Reminder Processing
Follow Up
Premium Receipts Processing
Premium Accounting
Report Generation

Policy Reconciliation's
Premium Reconciliation with Bank statements
Premium Reconciliation's with Employer statement
Report Generation for Regulatory and Statutory Compliance Requirements

Claims Management

Mailroom & Imaging
Paper Claims Receipt (UB 92, UB 04 CMS 1500, ADA)
Sorting / Prepping
Imaging
OCR / ICR

Pre-adjudication
OCR Data Capture Validation
Claims Data Entry (Hand written Claims)
Provider Eligibility Validation
Edit Resolution
Member Eligibility Verification

Adjudication
Coding Verification
Edit Resolution (Medical, Facility and Dental Claims)
Claims Re-pricing
EOB Processing
Member / Provider Communication Processing
Aged Claims Reporting
Claims Quality Audit

Collections
Over-Payment / Under-Payment Analysis
Root Cause Analysis
Provider / Member Follow Up and Recovery

Provider Network Management

Provider Credentialing
Collation of credentialing data like education, peer references, training, malpractice history, etc.
Verification of credentials
New Provider Profile Upload
Ongoing credentialing Support

Provider Contract Management
New Contract Uploading
Ongoing Contract Maintenance
Contract Renewal Support
Contract Performance Analysis

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 Payer Services

Medical Billing

Demographics Entry
Charge Entry
Coding
Claims Submission
Cash posting
Denials Management
Account Receivables Analysis
Account Receivables follow up

Hospital Billing

Demographics Entry
Charge Entry
Coding
Claims submission
Cash posting
Denials Management
Account Receivables Analysis
Account Receivables follow up

Post-Discharge and Post-Injury Billing

Indexing
Invoice Processing
Accounts Receivables
Claims Submission
Cash Posting
Denials Management
Account Receivables Analysis
Account Receivables follow up

Accounts Payables

Accounts Payables Analysis
Vendor Payments
Dispute Management
Vendor Mapping
Vendor Management
Customer Service

Clearing House

Explanation of Benefit Processing
Eligibility Verification

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 Payer Services

Member Enrollment
Member Enrollment Fulfillment
Doctor Credentialing
Mail Order Pharmacy services