Reference no: EM133151863

You are completing part of your externship at a small single-physician practice. The practice has been transitioning to an EHR system and are currently operating in a hybrid environment. The office manager has asked you to help her identify problems with the current billing processes and brainstorm ideas for a redesign that will reduce errors and increase efficiency.

The office manager explains they have a medical biller and coder in the office who is still learning the new records system. Recently they have been receiving numerous denials from Medicare for billing errors as well as complaints from the patients receiving bills due to non-payment from insurance.

Using the information, you gained this week regarding workflow analysis and process improvement, suggest cost-saving and efficient ways this practice can achieve an efficient billing process

HT2400 Week 5 Discussion Case Study

Hi, my name is Cheryl. I am a medical coder/biller at a small physician's office.

As you probably already know, since 1990, Medicare has required physicians and other providers of medical services to submit claims directly to Medicare on behalf of beneficiaries.

For our patients, the billing process begins when the patient is seen by the physician. During the visit, the physician records information about a patient visit and services provided in the patient's medical chart. In other words, the physicians make notes in the patient's chart during a patient visit. Because we are such a busy practice, many physicians use handwritten notes as reminders and as a guide when dictating patient visit information for transcribing. This information is usually conveyed to me, the medical coder/biller via a "source document" completed at the end of the patient visit. Every once in a while, the physician's assistant will code directly into medical billing software when they forgot a procedure was completed.
Our source documents are preprinted forms completed by the physician. Sometimes the physician puts handwritten notes on the source document as well. The source document is the tool I need to obtain information from the doctor. You wouldn't believe how difficult it is sometimes to get the physicians to provide this diagnostic information! I don't know why it is so hard. Our source documents list only the most common procedures and services provided to our patients. The physician simply needs to check off the procedure or service provided or hand enters services not on the preprinted form in space provided for this purpose. I use the source document to prepare the actual bills submitted to Medicare. Sometimes the documents are ambiguous, because there are only a limited number of codes listed on the document. That leaves me uncertain as to actual diagnosis and treatment provided to a patient. I know that if this source document is not properly completed, documentation in the patient's medical file will not support the services billed and the resulting claim will be incorrect. At the end of the day I obtain the list of patients who showed up for his/her appointment and compare the list to the pile of source documents. It is my responsibility to ensure that source documents for each patient seen that day are collected. Our completed source documents are entered into our own billing system. I am responsible for entering the patient, the provider, diagnosis, procedure, coding and other information needed for claim coding. I am also responsible for resolve any missing, incomplete or erroneous information detected either by the billing computer software or document review. Once the information is entered into the physician's billing system, it is subsequently sent to a clearinghouse, which, in turn, submits the claims to Medicare.

Medicare makes the payments in the name of the provider and sends it to a 'pay-to-address' designated by the provider, which is our office. In addition, Medicare sends monthly remittance notices to us showing what is billed under the physician's name. It is my responsibility to review the remittance notice and notify Medicare if I believe false claims were generated .

Questions

1. Explain two specific areas in the claim preparation and submission process described in the case study that could be causing the denials.

2. What suggestions would you make to the office manager to redesign the billing process described in the case study so that it can be more efficient?

3. Describe the two largest potential issues you think the office described in the background may face during the redesign of the billing processes.