This SOP is intended to provide visibility on what kind of tasks are completed by PFS2 representatives on the phone while providing billing services to patients.
This is applicable to any PFS2 agent, or any other personnel assigned to handle patient inquiries on the phone. For instance: TL’S or Teamcoaches taking care of escalated calls.
Daily Tasks Completed by PFS2 Agents:
Claims Handling:
1. Check & Provide Patient balance.
2. Provide claim information such as: date of service, cpt codes, bill amount, patient responsibility
for date of service, services provided/ details, ICD codes information, rendering provider
information and facility information where services were provided.
3. Provide claim Status (pending, Denied, or paid).
4. Review if claim was processed by insurance, and in case it was paid or denied, explain to
patient how it was processed & if there is any Patient responsibility let them know what's that
for (deductible, coins, co pay, etc.).
5. Go through all date of services to check payments made in case it’s needed just to clarify how
each date of service is being processed and paid.
6. Escalate incorrect payment posting issues, such as adjustment or denial received from
insurance was not posted correctly on patient’s account. Create a ticket or task.
7. Send itemized bill or transaction details report as per patient's request or any other authorized
person request; this can be sent either by fax, or by mail only.
8. Assist not only patients but also insurance reps with any questions they may have regarding
balances, charges, and insurance information we have on files for billed claims.
9. Submit charges to any new insurance added or updated on files, after running pt eligibility to
make sure insurance is active for DOS.
Tickets Handling & Disputes:
1. Submit tickets for any issues or disputes from the patient, for instance: missing patient
payments not being reflected on files (for payments made online, at the office or by check),
charges not recognized by patient, duplicate charges, refunds request, No show fees received
for cancelled appointments, Deceased notification received for a pt account (request to adjust
charges), discount request, collection balance dispute (request to be removed when they are
sent to collections incorrectly), wrong type of service billed, coding disputes, invalid rendering
provider name used. Also, agents need to follow up on the tickets with a 7-10 b days’ timeframe.
Patient Profile & Updates:
1. Update insurance information as per patient's request (agent are allowed to create insurance
cases, activate, or deactivate the ones depending on what we should have on files). Some
practices might have exceptions to this rule and a ticket will be required.
2. Update patient demographic information: address, phone number, names & last names (after
validating the information).
3. Add a guarantor on files once patient is verified and if we receive authorization either on the
phone or in case we receive any request in writing with a HIPPA form
Account Maintenance:
1. Place patient's account on hold when account is under review (change collection category for
this). Also add alerts on a patient account with any important information.
2. Work on collection report process and collection audit (sending list of delinquent patients to
CSC and wait for their response to confirm whether balances need to be written off, adjusted
off, or sent to collections). Once receiving a response from CSC, agents create a ticket with
CSC instruction, and they assign this to India's team to complete request.
3. Agent should always review patient statement options to confirm specific requirements we may have for each practice.
4. Request patients or any callers to send us POP, EOB'S, HIPPA forms, copy of insurance card,
patient demographic information and any other important documentation in case this is needed
to update our records correctly or to post claim information correctly. In this case, reps provide
either fax # or online address we have available for callers or patients to upload the information.
5. Post any valid Proof of payments received from patients (a bank statement showing transaction went through for the billed amount and including the right provider’s name, any office receipt, a
copy of a check, etc.). If is proof of payment is not clear, reps can submit a ticket to CSC so he
/she can confirm if this is valid or not
6. Agent should always document calls received with details on what pt called about, what was
done, and what was the resolution in the account profile, according to the PMS.
Payments:
1. Take payments if practice has stripe or any other patient portal available & apply payment to
pending date of services we have on files.
2. Sending payment receipts to patients for payments taken by reps on the phone, this can be
sent either by mail, fax, or email.
Practice & Provider Inquiry:
1. Provide practice address and phone number if requested by patient, and service location
information where services were rendered for a dos.
2. Provide rendering provider name, specialty, and location if Requested by Patient.