Reimbursement: "Whose job is it?" In many practices, unfortunately, the ready answer is, "The billing office's." In actuality, any staff person who works with the patient, the patient's medical record or financial account affects reimbursement. This article considers reimbursement a team sport and introduces several ways to en-sure the practice receives all the revenue due by asking each team member to play a part.
While the billing office staff is well-versed in the nuances of reimbursement, the other staff members may not be. Begin by providing them with the tools they need to succeed: coaches and playbooks. The coaches are the practice administrators, billing office managers and physicians who will oversee the entire process. They coordinate training, disseminate information and en-courage compliance with coding guidelines. Support for these coaches is vital. The playbooks are up-to-date resource material such as Medicare and insurance manuals, coverage policies, medical dictionary, ICD-9 manual, and CPT and HCPCS handbooks. Don't forget regularly used forms, intra-office policy memos and Web links to the websites of the various carriers. Ongoing staff training helps keep everyone ap-prised of policy changes and al-lows the staff time to ask questions and share information. Save any handout material from training seminars outside the practice and share it with everyone throughout the office.
The ophthalmic practices with collection success have great teams doing the work. Though not every staff person has an equal role to play, every member must be aware of the importance of the accuracy of documentation and coding, as well as the need for efficient procedures for collecting re-venue. To improve the efficiency of the collection effort, initiate the process as early as the first en-counter with the patient—the patient's phone call to schedule the appointment—and follow through with each staff member who is involved with the patient from that point forward.
Specific assignments for each member help clarify who plays which position. In large group practices, assignments are divided throughout the staff, while in smaller practices you'll find many tasks being assigned to just a few multitaskers. Rather than assign tasks to specific people within the practice, you may wish to break down the re-sponsibilities by department.
• Telephone switchboard/appointment desk. In addition to finding a convenient date and time for the patient appointment, the initial call to the practice is the ideal time to inquire about insurance coverage and who's responsible for payment. Besides verifying insurance information, remind the patient of any preauthorization requirements, such as: a referral from the primary physician; the consequences of not obtaining the referral, such as having to pay for the visit out-of-pocket; and the fact that the patient may have to pay for any non-covered services. Don't hesitate to repeat that the payment is due at the time of service.
• Front desk registration/reception staff. By check-in time, the patient has already discussed insurance and payments once. At registration, a staff member verifies the patient's demographic information. If done properly, this takes some time. Simply asking if the patient's address and employer have changed is not enough. Front desk personnel are also responsible for:
• reviewing demographic sheets with the patient to ensure that all fields were completed and information is current;
• copying insurance cards periodically to ensure that your files contain the most up-to-date information;
Since the front desk gathers information on a variety of plan requirements, such as which physicians are on which panels, which plans require a referral or authorization, and who is your liaison or representative at the carrier's office, be sure to compile a binder with this information so the front-desk staff can refer to it quickly.
Medicare beneficiaries and a number of patients with commercial insurance coverage are required to meet an annual deductible. Staff at check-in and registration must remind patients of their obligation and that payment is expected at the time of service. They can do this by simply asking the patient how he or she will be paying for the day's services.
Your front desk supervisor will oversee the activities of the registration desk and monitor the accuracy of the information being collected. When the supervisor identifies errors or omissions, she should use these failures as an opportunity to train and improve the front desk staff. Likewise, success deserves praise and continued encouragement to excel.
• Technicians and physicians. Traditionally, the clinical staff have downplayed or ignored the requirements of reimbursement. The clinical staff may believe they provide care and someone else worries about the money. In our team sport analogy, the clinical staff has an important role to play concerning chart documentation that complements the billing staff. Remember, the billing staff can only submit claims for services that were appropriately documented and properly coded. So, it's incumbent on the technicians and physicians to understand documentation and coding guidelines. Use the quiz in Table 1 to test how well your clinical staff would score on the documentation requirements for certain services.
This test is almost certain to reveal some uncertainties or deficiencies. Supervisors should provide training or develop a team-building program in which each person is assigned to re-search a single topic and share the results with the others.
The leaders of our team are physicians. While time constraints require them to focus on certain parts of the exam and delegate other parts, they are ultimately responsible for everything, including proper charting and coding. Complete and legible documentation is essential. Ancillary tests require an order, interpretation and report. Code selection, particularly as it reflects medical necessity and the gravity of the disease, is also the team leader's responsibility. While a staff person may suggest CPT and ICD-9 codes, the physician validates the choice on the encounter form or route slip. Remind the physicians how vital the medical record is to the claims process. The staff will follow the physician's lead.
• Billing office. The front line of our team is the billing office staff. They deal with a host of issues: different instructions from different insurance carriers, changing policies, handling denials, handling patients who are upset about charges and physicians who are upset about collection. They try to capture every dollar the practice has earned by following efficient billing procedures. Those procedures are constantly changing as reimbursement rules and regulations evolve. However, missing information in the chart or registration forms short-circuits the efforts of the billing office. For example, incomplete demographics make claims submission impossible for the billing department; the rest of the team must be sure to collect all the required information.
Team building and continuing education help develop a group that works well together and improve the quality of the chart documentation, the accuracy of the claims and the efficiency of the collection effort. To assess performance, schedule periodic internal chart and claim audits. A team of auditors may work better than assigning this task to a single employee. Consider a team that includes a technician, a physician and a biller to get many different points of view.
Contact Ms. Johnson (909) 890-2202 or mpjohnson@