PBSI Services - Healthcare
With over 40 years of continuous service to the healthcare industry, specifically
in the Medicare arena, PBSI has expertise in the business of health and health information
services. We have subject matter experts and provide specific support in the following
areas:
Claims Processing
PBSI has been processing financial transactions since the inception of
Medicare. We understand the workflow and operations relating to entering and
processing claims data through the two Shared Systems (FISS for Part A data, and
MCS for Part B). We can process claims accurately and timely and help your
business maintain the lowest unit cost per claim. Through the implementation of
POWER we have been able to streamline the claims
processing workflow to minimize paper, eliminate redundancy and increase the
probability of first-pass processing. This saves our client’s bottom line
dollars.
Our Part A and Part B Operations were recently recognized in June 2006, as an ISO 9001:2000
registered quality program by an independent registar.
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Provider Customer Service Program
PBSI has ISO certified processes for the control, tracking and processing of
inquiries throughout our Customer Service Program. PBSI’s Provider Customer
Service Program is a comprehensive, coordinated, and integrated program that
provides high-quality and timely information, education, and training to
providers.
Through the use of tools such as IVR, newsletters, Web based training,
seminars and Webinars, presentations and so on, we are able to keep providers and beneficiaries
up-to-date with current, accurate and timely
information.
In addition, we help during times of national crisis. PBSI received
commendation for our handling of extraordinary pressures caused by Hurricanes
Katrina and Rita. PBSI’s contingency plans and our tools successfully abated many
issues caused by the storms. More importantly, the PBSI staff worked arduously
until services were
restored.
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Appeals
The appeals function is designed to ensure providers and beneficiaries
receive due process in having initial claims decisions independently reviewed. The first level of
appeal for a processed claim is redetermination. A second level appeal,
reconsideration, may involve a Qualified Independent Contractor (QIC). PBSI
subject matter experts are qualified in handling all aspects of the appeal life
cycle.
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Audit and Reimbursement
Audit and Reimbursement is the first and last line of defense in the
appropriate use of the Medicare Trust Fund. Upholding program payment policy,
while at the same time offering excellent customer service, has been our
reputation for the past forty years.
We have experience with:
- Audits
- Cost reporting
- Desk Reviews
- Provider Base Reviews
- Settlements
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Medical Review/Local Coverage Determinations (LCDs)
The main goal of the Medical Review program is to reduce errors in claim
payment. The key element in the effort to reduce errors is the development of an
MR strategy. This strategy is driven by data analysis, which directs the
necessary action to be taken, such as probe review, edits and audits. PBSI has
staff dedicated to performing medical review and validating claims data. If corrective action is needed, our staff is trained to develop collaborative
educational strategies so that future claims are processed on the first pass
through.
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Comprehensive Error Rate Testing (CERT)
Each Medicare claims processing contractor needs to minimize the number of
provider compliance errors. To this end, a Comprehensive Error Rate Testing
(CERT) program is mandated to minimize these errors and paid claim errors.
PBSI has formed a CERT Task Force that focuses on educating providers about CERT
and requests for medical records. We partner with medical associations to
aid in educating providers on the importance of CERT.
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Medicare Secondary Payer (MSP)
PBSI's subject matter experts average 11 years of experience in performing
MSP. We have staff ready to assist with:
- MSP Debt Collection and Referrals
- MSP Post Payment
- MSP Prepayment
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Fraud and Abuse
Fraud and Abuse costs beneficiaries on many levels. PBSI is responsible, as a
Medicare contractor, for detecting and deterring fraud and abuse within the
program. We recognize the special emphasis placed on the impact of fraud and
abuse within HIPAA legislation, which established the Medicare Integrity Program
(MIP). PBSI has skilled experts that analyze data and medical review files for
early detection of potential fraud, waste or abuse.
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