It’s all about Flow [Part 1]
Most patients don’t have a clue about how doctors get paid; it’s not by magic.
Yet, a number of different steps occur during the processing of a medical claim as can be seen in the flow chart below. Each step within the process can be mapped out and each is subject to claim payment-or-claim abortion or rejection.
The steps can also be subjected to a number of variables, depending on a number of different factors including staff competency, time, outside vendors, information management, management decisions in general, or regulatory requirements.
Of course, any one of these points could lapse, causing the entire process to break down. Like treating patients, when the process has no variables, the end result is very predictable, such as in the flow chart below. When there are variations the end results can be very different.
Treatment is Only the Beginning
Doctor gets the chart
Doctor evaluates patient
Doctor documents visit
Doctor marks billing slip
Doctor gives slip to patient
Patient gives slip to billing clerk
Billing clerk enters information into computer
Office staff submits claim to insurer
Third party payor/Insurance company receives claim
Insurer adjudicates claim
Reimbursement transmitted (electronic or mail) to practice
Reimbursement entered (posted) into practice management system by office staff.
There are two things that you need understand in order to implement an efficient compliance program.
1] The first is the processes needed to run the organization and the desired outcome of those processes.
2] And second, if the process needs improvement, what can be done to make the process function better?
Office Efficiency Checks
Most small medical and dental practices or clinics have a number of checks and balances in place to control variation.
In an example of an inefficient operation, one practice had the physician-executive open every envelope that came into the office. This was done because of a concern that if someone else did it, then something could go missing.
However, the doctor would then turn the mail over to the payment posting person, who would enter claims into the system. Sometimes the person who entered the claims would become busy with other duties and would not be able to enter claims for a couple of days. This proved to be an inefficient method of managing the billing process for the organization.
A possible solution is to have one person in the front office to open the mail, organize the contents based on who needs to deal with the information (such as claims, refusals, or requests), and then distribute them accordingly.
More on how physcians get paid.
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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com
OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors