Case Studies

Established in 1988, AMBS Inc has solidified its position as a premier provider of medical billing services across the United States. With a steadfast commitment to affordability and excellence, they offer healthcare providers a dedicated team of experienced billing professionals, poised to navigate the intricate landscape of medical billing and insurance with finesse. Through their unwavering dedication to efficiency and innovation, AMBS empowers healthcare providers with the tools and support needed to optimize cash flow and minimize administrative distractions.

For the past 18 years, Rheal has been a trusted development partner for AMBS, spearheading the creation of their Practice Management System (PMS) and a suite of complementary systems listed below. These cutting-edge solutions not only enhance the functionality of the main system but also add significant value, equipping healthcare providers with the tools they need to thrive in an ever-evolving healthcare landscape. Together, AMBS and Rheal are revolutionizing medical billing and practice management, driving success and efficiency for healthcare providers nationwide.

• Practice Management System
• Claims Management System
• Provider Credentialling
• Patient Portal

For AMBS, the advent of their Practice Management System (PMS) heralded a transformative era in business expansion. As pioneers in revenue generation through Billing and Claims management, they faced the cumbersome task of navigating through paper claims and text-based emails for data processing.

The pivotal shift came with the development of a HIPAA-compliant PMS, which not only streamlined their internal operations but also empowered practices with seamless management solutions. This groundbreaking innovation not only revolutionized the accessibility of billing information but also ushered in an era of unparalleled efficiency, where billing became effortless and claims processing was expedited to unprecedented speeds. Thus, the implementation of the PMS marked a milestone in AMBS's journey.

Below is the list of important functions that have been developed to support smooth operations.

Practice Administration

Whenever new practices sign up, the most important step is to set up the various aspects without which they cannot start using the system for the operations like creating patients, scheduling appointments, encounters etc. Below is the list of things that needed setup.

1. Appointment timings
2. Providers
3. Billing Company
4. Clearing house settings
5. Payment gateway settings
6. Insurance companies
7. Multiple Fees schedules
8. Super Bills
9. Codes
   • CPT Codes – Procedures (Treatments)
   • ICD Codes – Diagnosis
   • Adjustment codes
   • Payment Codes

Patients and Appointments

When patients are created in the system, apart from the personal and contact details, below is the list of critical information required every time they come for an encounter.

1. Insurance – Primary / Secondary and Tertiary
2. Authorizations in terms of
   • Visits
   • Amount
   • Units
3. Repeated Diagnosis and Procedure codes

Appointments for patients can be scheduled based on the practice settings for appointments like max time slots, allow multiple patients in one time slot, earliest and the latest time for appointments etc.

Email / SMS reminders of appointments are sent to patients again based on the practice settings of whether to send one day or two days prior or on both the days. Summary of the appointments list is sent by email to the providers for each day, so the provider gets an idea of the schedule set for them.

If a patient has defaulted on payments, alerts are raised while setting up appointments for such patients.

Encounters

In our healthcare application, an encounter stands as the pivotal moment where patient care intersects with administrative efficiency. Across hospitals, clinics, and private practices, these encounters serve as the backbone, capturing vital data essential for billing and claims processing. Here, healthcare providers meticulously document crucial details—ranging from medical history to current symptoms—ensuring comprehensive care delivery.

Every encounter holds a wealth of information, including patients' insurance details and authorizations, meticulously recorded to facilitate seamless claims generation and submission to insurance companies. With each encounter, bills are meticulously crafted, leveraging the wealth of information gathered to generate accurate invoices swiftly integrated into our billing system.

Claims management

This segment encapsulates the cornerstone functionalities, including the comprehensive processing of claims spanning primary, secondary, and tertiary stages, alongside managing patient responsibilities arising from partial payments made by insurance companies. Developed and released in 2011, the electronic claims generation module seamlessly integrated into our application, enhancing its capabilities exponentially. Below, we delineate the pivotal functions that epitomize the core essence of this system, underlining its indispensability in modern healthcare operations.

1. Claims in Print Format are as below.
   • HCFA-1500 (CMS-1500) used to submit charges covered under Medicare Part B. (Mostly small practices which cover day care and OPD)
   • The UB-04 (CMS-1450) to submit charges under Medicare Part A. (Mostly covers hospitalization related procedures / surgeries)
2. Claims in Electronic format.
   • EMC – for all types of hospitalization

Independent Claim Generation and upload:

As AMBS blazed a trail in the realm of medical billing, an increasing number of billing companies adopted our billing application. Consequently, the volume of claims surged dramatically, experiencing a six to sevenfold increase since 2011. To meet this escalating demand and ensure optimal performance, we devised autonomous processes tailored for batched claim generation and seamless uploading to insurance company servers. These processes are strategically scheduled to run during non-working hours, aligning with the preferences of billing companies and maximizing efficiency without disrupting daily operations.

Processing Electronic claim reports:

This process posed a significant time burden on AMBS staff members. Remittances of the claims sent arrived in electronic form, encoded and awaiting decoding. Recognizing the need for efficiency, we swiftly developed a decoding module, seamlessly integrating it into our system. This enhancement not only streamlined operations but also bolstered the popularity of our billing application. With each success story, the demand for licenses surged, attracting a growing number of billing companies eager to harness the power of our solution.

The credentialing application was meticulously designed to streamline the intricate processes inherent in validating the qualifications, expertise, and background of healthcare providers seeking affiliation with a designated health plan or network. Spanning multiple stages, the credentialing process entails gathering and scrutinizing a myriad of documents and details, encompassing a provider's medical licensure, educational achievements, malpractice coverage, and professional tenure.

At its core, credentialing serves a paramount purpose: to uphold stringent standards of excellence and patient welfare, ensuring that healthcare providers possess the requisite skills and competencies to deliver exceptional medical care within a specific healthcare setting. Typically overseen by a third-party credentialing organization or a managed care entity, this rigorous process involves meticulous examination and authentication of a provider's credentials, safeguarding the integrity and quality of healthcare delivery.

The patient portal represents a hallmark of healthcare innovation, adhering to strict HIPAA compliance standards while empowering patients with unprecedented access to their personal health information. Engineered for convenience and accessibility, this intuitive platform equips patients with the tools to manage their health and healthcare needs seamlessly, irrespective of time or location.

Patient portals offer a diverse array of functionalities, including:

• Appointment Management: Patients can effortlessly request appointments, view upcoming schedules, and receive timely reminders, streamlining the scheduling process for both patients and providers.
• Access to Medical Records: Patients gain access to their comprehensive electronic medical records (EMR/EHR), enabling them to review past appointments, encounters, diagnoses, and procedure codes, fostering informed decision-making and continuity of care.
• Billing and Claims Visibility: Patients can conveniently review their past bills, claims generated, and payments processed by various insurance companies, along with any associated patient responsibilities, ensuring transparency and clarity regarding financial matters.
• Online Bill Payment: Simplifying the payment process, patients can securely view and settle their outstanding bills online, enhancing convenience and efficiency in managing financial transactions.

By harnessing the capabilities of patient portals, healthcare providers witness a transformative shift in patient engagement, care accessibility, and communication dynamics. This technological advancement fosters proactive patient involvement in their healthcare journey, facilitates greater access to care resources, and fosters seamless communication channels between patients and healthcare providers, ultimately advancing the quality and efficacy of healthcare delivery.