All successful management strategies start with a plan. Changing work procedures as you are going along, in a piecemeal basis confuses staff and creates chaotic work environment. Before introducing or implementing new work strategies, observe your practice’s daily routine. Take input from all staff, then make a plan. Draw out a clear diagram to guide you, the manager, doctors, and staff. A well-planned workflow diagram takes into account all tasks, big and small, performed in the office. It is a map that leads to successful management and increases productivity. Revisit your workflow diagram in intervals to make changes to better suite your practice needs.
- Identify the patient’s needs.
- Schedule patient for correct service and practitioner.
- Collect full demographic information.
- Collect all insurances information.
Medical Billing Department
- Verify patient’s insurance coverage.
- Identify primary, secondary, and other payors.
- Determine referral/authorization requirements.
- Identify any Co-Pay, Co-Insurance, and deductible.
- Make notes of all findings in patient’s file.
- Inform patient ahead of visit date about any health/vision benefit issues which need to be cleared with insurance.
- Verify patient’s contact information.
- Verify insurances on file.
- Scan in any new insurance card or referral into the system.
- If patient has a balance, have a statement ready to hand over.
- Collect any cost-share amount determined by the Billing Department.
- Be aware of patient flow and wait time.
- Any patient waiting for more than 15 minutes should be attended to.
- Briefly explain to patient which services will be provided for the visit.
- Make proper handover to front desk for checkout and follow-up appointments.
- Check for any existing appointment before creating a new one.
- Let patient know what may be done at the next appointment.
- Hand over appointment card to patient with your initial on it.
- Review appointment detail with patient to confirm scheduled appointment matches with patient’s copy.
- Print out the appointment schedule.
- Cross check open claims with schedule to make sure claims have been generated for all patient visits.
- Review exam notes and claims for proper documentation.
- Identify any billing and claim issues which need follow up.
- Review all authorization/referral for validity.
- Check Place of Service, modifiers, NDC codes, and insurance information on the claim form.
- Check the insurance cards one more time to make sure claims are going to proper payor.
- Know your payors –Maintain active list of payor rules, LCDs, insurance addresses, fax#, etc.
- Claims must be created and submitted within 24 hours of patient visit.
- Submit claims electronically whenever possible. This way you have proof of timely filing. This way claims will get processed and paid faster.
- If e-claim is not possible, try to get fax number for the insurance claims department to send claim.
- If case you have to mail any claims, keep close track of the claims.
- Claim Transmission Time:
- Electronic transmission through clearing house – 3 working days
- Fax transmission – 3 to 10 working days
- Paper claims by mail – 10 to 20 working days
- Review clearing house rejections, software rejections, and EOBs (Explanation of Benefits) for non-pay claims every day. This should be the first thing you do before starting any other work. All issues should be resolved the same day you receive them.
- Post all payments and review all postings.
- Review EOBs (Explanation of Benefits) to be certain that insurance is paying according to contracted rate.
- Run end-of-day report to cross check payment posting.
- Generate Insurance Aging Report and follow up on any claims past 30 days.
- Generate patient aging report, send out statements and follow up on delinquent accounts.
- Analyze production report to highlight strengths and obstacles in the practice.
- Analyze monthly reports of rejections, pended claims, and unsolved issues.