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A Perfect Day in Your Medical Practice: The Efficient and Well-Run Medical Office

Posted by Mary Pat Whaley on August 24, 2010

Image via Wikipedia

All available appointments are full.
All staff showed up for their shifts.
No one burns toast in the toaster oven and sets off the fire alarm.
None of the staff show up to work wearing flip-flops or pink underwear beneath their white scrubs.
All patients have been reminded about their appointments so they all show up.
Patients calling for same-day appointments are able to be worked-in appropriately.
No patients give false information at check-in.
Established patients arrive on time with their insurance information and co-pay.
New patients arrive on time to complete their paperwork, and give their insurance card, photo ID and co-pay to the receptionist.
Patients with x-rays or other imaging studies bring the films or a CD.
Patients with fasting appointments arrive having fasted.
All patients arrive bringing their bag of medications.
Patients in wheelchairs and with difficulty ambulating are accompanied by caregivers.
Patients who do not speak English or are deaf have notified the office prior to the appointment and the appropriate technology or interpreters are available for the appointment.
Patients with procedure appointments have followed their pre-procedure instructions.
Patients with procedures have been pre-authorized by their insurance carrier and their personal financial responsibility has been discussed with them and payment arrangements have been made.
Patient eligibility has been checked and those unable to be authorized have been called before their appointment to gain further information about their payer source.
If computers go down, there are paper procedures in place to enable staff to continue seeing patients.
No patients arrive saying “I forgot to tell you, this is Worker’s Comp/ an auto accident/ a liability case and I was told by my lawyer not to pay anything.”
None of the patients pee on a waiting room chair.
Neither JCAHO nor any state or federal officers show up.
The copiers and faxes all work.
No subpoenas come in the mail.

Image by Smithsonian Institution via Flickr
It’s not your very first day live on electronic medical records.
All phone calls are answered before the third ring and no one has to leave a message.
No patients walk in the door with severe chest pains and say “I knew the doctor would want to see me.”
Patients remember to call the pharmacy for refills.
Providers all run on time and seem in particularly good moods.
Patients get their questions answered with callbacks within two hours.
Someone delivers sandwiches, drinks and brownies to the practice for lunch. There is enough for everyone.
No bounced checks come in the mail.
Providers spend so much time in the exam room listening to their patients that the patients leave feeling that every question they had (and a few they didn’t know they had) was answered.
Providers circle the services and write the diagnosis codes numerically on the encounter form, remembering that Medicare doesn’t pay for consults any more.
Sample medications that providers want to give patients are in the sample closet.
Records that providers want to reference are in the chart and are highlighted.
No one calls urgently for old medical records that are in the storage unit across town.
There are no duplicate medical records.
Patients checking out never say “But he was only in the room for 5 minutes!”
The patient restrooms don’t run out of toilet paper.
No bankruptcy notices come in the mail.
All phlebotomists get blood on the first stick.
No kids cry.
The HVAC system works beautifully, keeping it cool where it needs to be cool, and warm where it needs to be warm.
Congress announces that the SGR formula has been revoked and a new reasonable model for paying physicians has been discovered.
Everyone goes home at 5:00 p.m., glad to have a job, glad to be of service, and happy with their paychecks.

Tags: appointments, callbacks, check-out, chest pains, Congress, diagnosis codes, EMR, fire alarm, happy, interpreters, Medicare, patients, pharmacy, phlebotomist, practice management, providers, refills, registration, sample medications, satisfied, SGR, staff, toaster oven

Posted in: A Career in Practice Management, Day-to-Day Operations

Who Does What in a Medical Office: Basic Position Descriptions

Posted by Mary Pat Whaley on May 23, 2010

Front Desk/Check-In

Greets patients and visitors to the practice
Registers patients in the practice management system which may mean entering information given verbally or on registration forms
Collects identification and insurance cards and copies or scans them for the record, may photograph the patient for the record
May collect co-pays or other monies
Prints encounter form (also called superbill, routing slip, or fee ticket) with updated information, or updates information on the encounter form
Has patient sign financial agreement, receipt of privacy policy, benefits assignment, etc.
May answer phone calls, take messages and make appointments
Directs visitor (drug reps, salespersons, etc.) appropriately

Medical Records

Primary responsibility for the integrity and management of the medical record, whether paper or electronic
Controls record filing (paper) or indexing (electronic)
Fulfills requests by patients, attorneys, insurance companies, and social security for release of records
May manage paper faxes and messages by attaching to charts and delivering to provider
May prepare paper charts for chart audits by payers or others
May be the HIPAA Officer

Medical Assistant, LPN or RN

May assist Physician, Nurse Practitioner or Physician Assistant with procedures
Depending on state laws, may give injections
May perform procedures independently (ear wax removal, staple removal, etc.)
Provides Medicare patients with an Advance Beneficiary Notice if any lab test or procedure to be performed in the office will not be covered by Medicare
May perform phlebotomy (draw blood)
May collect specimens, perform basic laboratory tests and chart results
Provides patient education verbally and by providing written materials
May schedule tests or procedures ordered by the provider
May schedule surgery and prepare surgery packets for providers (*this may be delegated to a surgery scheduler if this position exists)
Calls patients about test or procedure results; returns patients calls with answers after consulting with provider
Prepares exam room for procedures (PAP smears, excisions, etc.), marks specimens for lab and pathology
Cleans exam room after each patient and stocks exam and procedure rooms with supplies
May be responsible for ordering office medications and medical supplies
May perform lab controls daily and check and record temperatures on lab refrigerators and freezers

Triage Nurse

Takes incoming calls from patients and gives them medical advice according to predetermined nursing protocols
Makes decisions about patients needing to be seen urgently, same day or next day
May be delegated callbacks from providers or other nurses
May see walk-in patients and triage their condition

Lead Nurse, Charge Nurse, or Nurse Supervisor

Assigns clinical staff specific responsibilities
Manages clinical staff schedules, using agency or temporary staff as needed
Performs annual competency exams on staff
Ensures all staff are current on licenses, continuing education and CPR
Problem-solves patient issues
May be responsible for ordering office medications and medical supplies
Has responsibility for medication sample closet upkeep
May perform annual evaluations fro clinical staff
Responsible for equipment maintenance and makes recommendations for medical equipment as needed
May be the Patient Safety Officer and the Worker’s Compensation Coordinator

Referral Clerk

Reviews orders written by providers and determines where test and procedures may be performed based on patient’s insurance
May provide the patient with information about the test or procedure cost and what the patient’s financial responsibility is estimated to be
Pre-authorizes, pre-certifies, or pre-notifies the test or procedure if required by the patient’s insurance company
Schedules the test or procedure
Provides the patient with information about preparation for the test or procedure

Lab Technologist/ Phlebotomist

Receives laboratory requisitions from provider and collects specimens according to provider order
Provides Medicare patients with an Advance Beneficiary Notice if any lab test or procedure to be performed in the office will not be covered by Medicare
Performs tests or packages specimens to be transported to reference lab
Receives results back from the labs and matches them to charts
Performs lab controls daily and checks and records temperatures on lab refrigerators and freezers

Check-out Desk

Reviews services received by patients, checking to make sure that all services received were checked on the encounter form
Enters charges in the computer system for services received
Tells patient if any additional monies are owed if co-pay was collected at check-in
May sign patient on to a payment plan if needed
Takes monies owed, posts monies and produces a receipt for the patient
Makes return appointment for the patient if needed, or enters recall into the practice management system

Biller or Collector

Corrects claims that are rejected from the claims scrubber, clearinghouse or payer
Files secondary and tertiary claims as needed, electronically or via paper
Posts receipts from insurance companies and patients and edits any electronic remittance advice; may post from lockbox account on the web
May prepare deposits and/or make deposits
Generates patient statements
May check eligibility on patients with appointments and call patients whose insurance is not active (*may be delegated to a financial counselor if this position exists)
Calls patients who have not made payments in response to statements
May turn patients over to third-party collectors
Takes phone calls from payers or patients about billing issues and resolves issues

Coder

Reviews notes from inpatient or outpatient encounters and codes them according to the documentation
May post charges for services rendered
Audits chart documentation for quality purposes to ensure that provider coding and documentation is synchronous
Introduces changes in procedure (HCPCS) and diagnosis (ICD-9) codes and educates staff on the use of new codes
Ensures encounter forms and practice management software is updated appropriately with new and deleted codes
May be delegated the Compliance Officer

Billing Supervisor

Reviews the work of coders, billers and collectors and performs quality audits to benchmark acceptable error rates
Prepares or reviews deposits and tracks daily charge, collection, write-off and deposit information, watching for monthly abberations by payer or date
Reviews Accounts Receivable (A/R) reports, looking for trending or specific problems to be addressed with staff or payers
Brings to the attention of the Office Manager or Administrator any issues with non-standard payment trends, denials or non-covered services.
Performs evaluations for billing department staff
Takes escalated patient complaints
May credential providers with new payers or recredential providers with payers or hospitals

Office Manager, Practice Administrator, or Practice Manager (see the Library tab for job descriptions) see my posts on what an administrator does here, and a day in the life of an administrator here

Performs all human resource functions for the practice
Has ultimate responsibility for all money flowing in and out of the practice – makes deposits, pays bills, etc.
Contact person for all computer system, equipment and phone system issues
Responsible for day-to-day operations, advises supervisors on issues and problems
Resolves escalated patient complaints
Meets with vendors and researches possible practice purchases
Negotiates all practice contracts
Meets with staff and providers on a regular basis

These descriptions will not perfectly fit most practices, this is just a generalization. Each practice divides duties based on the number and skills of the staff in their office, and their specialty. These descriptions should help to define what the basic tasks are in most practices.

Tags: biller, billing supervisor, charge nurse, check-in, check-out, coder, collector, front desk, job descriptions, lab technologist, lead nurse, LPN, medical assistant, medical records clerk, nurse supervisor, office manager, phlebotomist, practice administrator, practice manager, referral clerk, RN, triage nurse

Posted in: Day-to-Day Operations, Human Resources

Patient Collection Question #1: How Do I Know What to Collect at Check-Out?

Posted by Mary Pat Whaley on December 21, 2009

My book on front-end collections has been doing really well and I’m pleased that a number of people have called me or emailed me with questions. Here’s one question that a number of people have asked – “Can you tell me more about knowing what to collect from the patient at check-out”?

Hopefully, you have followed my advice and collected co-pays and previous balances before the visit. The portion that you collect after the visit is the co-insurance and the deductible.

The guideline on collecting after the visit is directly related to the allowables on the services the patient received. Allowables are the amount that payers consider payment in full. Of the total allowable, a portion will come from the payer and the balance will come from the patient. Knowing that percentage is the secret to collecting at the check-out desk. The percentage of the allowable that the patient will pay is the critical piece of information you need to successfully and accurately collect after the visit.

Allowables fall into three categories:

The Medicare allowable for your area of the country, or state, for the current year. If you participate with Medicare, you have an allowable, if you do not participate with Medicare, you have a limiting charge that you must use for Medicare patients.
The allowables for the payers with whom you have contracts and have agreed to accept their rate for their subscribers.
The rates paid by payers with whom you do not have a contract. Their payment for out-of-network services (non-contracted physicians) will determine the amount owed by the patient.

How Do You Collect This Information – Medicare

Medicare allowables are published every year, both in the federal register and online at the CMS (Centers for Medicare and Medicaid) website. If you are fortunate enough to have a practice management system that loads this information automatically for you, you are golden. If not, you will need to enter these manually. The good news is that very few practices need to add more than 50 – 100 allowables to get started.

You can also use a paper cheat sheet to fill in your top 50 – 100 codes. Make a chart with your fee, the Medicare allowable, and the 20% of the allowable that Medicare patients must pay at every visit. A note of caution – many Medicare patients have secondary coverage and it can be difficult to know what the secondary coverage will pay. Most practices will not collect anything for patients with secondary coverage because it can mean a lot of refunds have to be written when the secondary payments come in.

How Do You Collect This Information – Payers You Have Contracted With

If you have a contract with a payer, they must furnish you with a full allowable fee schedule, or with an payment model. For example, their payment model may be 150% of the 2007 Medicare schedule. You will need to go to the CMS lookup page here and get these allowables for your services for 2007 and multiply it out.

Example: the 2007 allowable for 99213 established patient office visit is $56.98 for North Carolina (use your locality)

If the payer is paying 150% of that allowable, it will be $85.47, and if the patient has to pay 20% of that allowable, they will owe $17.09. Don’t forget to include the deductible in this equation, as the patient will need to satisfy the deductible before the payer will pay you 80% of their allowable.

Some practice management systems will have the ability to take that information and calculate it for you, so be sure to ask your vendor about this before you do the work.

If you are constructing a manual cheat sheet, you’ll have your fee (even though it doesn’t come into play, I suggest practices always keep their fee on cheat sheets, so staff can bring anything unusual to the administrator’s attention. Also as you increase fees, you have a handy visual.) Add the payer’s allowable, and calculate the percentage the patient will owe.

Use this same sheet for your payment posters to make sure you are getting paid the correct amount if your practice management system doesn’t do this for you.

By the way, if an insurance company that you have contracted with refuses to give you a schedule of allowables or a payment model, contact your state medical society, your state insurance commisioner, or your state legislators for help.

How Do You Collect This Information – Payers You Have Not Contracted With

If you do not have a contract with a payer, getting information on their allowables can be tough. Some practices will have the patient pay in full and either file the claim for the patient, or give/mail the patient a claim form for them to submit. In this case, you do not need the allowables. If your specialty has higher in-office fees due to tests, etc., it may be difficult for a patient to pay $250 – $500 in full at time of service. You may want to consider one of these strategies for collecting at time of service:

Collect a deposit based on the total charge. Let the patient know it is an estimate and that more or less may be owed. I do not believe in sending statements. In my book I recommend using a payment portal to securely store patient credit cards, and adjust the remaining balance up or down according to the actual payment. As payments come in you can develop a knowledge base for what different payers and plans will pay. This will assist you in estimating the patient’s portion more accurately over time.
You can give patients information about the services they most likely will receive at their visit and ask them to call their payer and get information on payment. This is a great strategy. If patients are shocked about their portion, they may want to reconsider becoming your patient. The last thing you want is a patient who is surprised by the payment due after they have received the services. Some payers supply subscribers with allowable information on their website.
You can usually get the allowable information by phone if you have the subscriber’s information, or if you have the subscriber on a three-way conference call, or in the room with you. This is more typically done when the subscriber is contemplating surgery or an expensive procedure and you are working on a payment plan, or outside financing with them.

Knowing what the patient owes and making arrangements for payment in full at time of service is one of the most significant things you can do to increase your receipts and decrease your accounts receivable. No practice can afford to “wait and see what insurance pays” and bill the patient months after the service has been rendered.

Click here to view “The Smart Manager’s Guide to Collecting at Check-Out.”

Tags: allowables, check-out, CMS look-up page, front-end collections, limiting charge, Medicare, patient-responsible balance

Posted in: Collections, Billing & Coding, Day-to-Day Operations, Medicare & Reimbursement