The scenario is inaccurate coding and lack of patient information which delays payments for the doctor. As head of the billing department a process will be implemented to solve problems on this issue. The current process is not working and because of the loss of productivity, a team was assembled to solve problems. The goal is to find where the error is, and recoup the loss revenue.
The first person to question would be the front office personal who checks in a patient upon arrival. After getting the insurance card and demographic page, it is important to compare that information on file to be certain it is accurate, and up to date. A copy of the insurance card should be taken at every visit. Even if the patient were there just there a few weeks ago, it is important to establish a routine of quality. Second, the front office personal should check the insurance carrier to see if a referral is necessary. However, most insurance carriers do not require a referral for family practice it is advantageous to determine if the doctor is in network.
When the patient is called back to their examining room, the medical assistant will ask for the reason for the visit. It is up to medical assistant to write down the signs and symptoms of the patient. The documentation must be detailed and recorded properly on the patients face sheet. The department manager of nurses should be scrubbing the documentation before it is submitted to the billing department. For example, if a patient has a routine check and the physician decides to order labs, the lab draw must be documented; even though it was not the reason for the visit.
The communication starts with the first point of contact, which is the front office. This person must be detailed, efficient and willing to ask questions without hesitation. They do not assume or fill in the blanks. They are assertive and responsible, to answer staff questions. Without this, the team will spiral downward like a domino effect. For example, the check out personal will not be able to excuse the patient without collecting the co pay. The co pay is not determined unless the insurance is entered correctly by the front office. According to Veean (2012) “We are paying more attention to electronic devices than to one another. The person to person communication between doctor and staff; and doctor to patient is decreasing. The answer to the question, is we can save health care by utilizing a balance of words and computers”.
The team will be organized by personality types. Keeping in mind the group of people has a variety of experience, skills and talents working to help each other achieve a common goal. The group has the task of problem solving why the billing codes are incorrect, and where the missing link is for payment. According to Chong (2007) “team performance can be positively correlated with the teams that are organized based on their individual characteristics”. Each person will be responsible for their role. Selecting the team by department will make sure all employees are contributing to their individual duty and this will equal success. There will be one leader, a couple of nurses to scrub the documentation for errors, two administration personal to make sure the demographics and insurance information is correct. A person from the billing department who will run a report from the last 120 days. The doctor also needs a friendly reminder, to document according to the procedure. The doctor must know that treating patients is not their sole responsibility in an office.
Consequently, all team members were selected according to their talents and skill level. How well they communicate with written and verbal communication. According to Cheesebro, (2010) the ability to solve problems and think critically are good traits to have. They have a desire to accomplish the task and be held accountable for their performance.
The potential for conflicts would consist of pointing fingers and judging without investigating. A person might already know who the employee is that started the problem and approach the person, unprofessionally. The process needs to be redefined and no one should be singled out as the culprit. Furthermore, a conflict may ignite if communication is not open. Hence, one person might feel an idea or strategy is not helpful to reach the goal. Although, good teamwork creates a positive environment. If there is a heated disagreement, it can lower the mood, and demotivate the rest of the team. However, according to Cheesebro, (2010) Conflict is healthy in certain situations, because it will bring a team together. Research has shown, employees who feel part of a strong team are happier and more productive. An acronym for team is: trust, empathy, attitude and mutual respect.
In conclusion, the best way to avoid future billing failures is to call the insurance company. According to University of Florida, College of Medicine, (2010) Cigna, United Health Care, Medicare and Medicaid will notify the billing office the reasons for denial. It could be as simple as the birth date does not match what is on the enrollment application. A modifier was not placed after an International Classification of Disease, 9th Revision (IDC-9) code. Perhaps the Current Procedural Terminology (CPT) was entered as a 4 digit code instead of a 5 digit code. Even though a report will catch this error, if a person overlooks uploads it electronically anyway, it will be denied. The rules for assigning these codes are complex, and have a significant role in coding; so that payment can be received. For example, if a bill for CPT 31256, nasal/sinus endoscopy would not be supported by ICD-9 826.0, closed fracture of the foot. This claim would be rejected and sent back.
In most offices, it is presumptuous to label the front office as the reason for failure in payment. It could be anyone’s guess the reason; hence a team approaches to solve the mystery of lack of payment is effective to problem solving. A person from the billing office would concentrate on these rejected claims, repair the error’s, and return them for payment. They will have 15 days to reprocess the claims, and recover the blunder.