Corrie Crittle

HCR/220

Medical Building Process

Documentation at the Front Desk:
The patient hand over an insurance card, this case the patient has Humana. On the care the office manager needs to verify if a referral or pre-authorization needs to be obtained and then contact the respective Primary care physician and get his documentation. Insurance verification data and a copy of the insurance card is sent to the billing office. The billing office scans the information and saves the documents. The Scanning department retrieve the information and it sent to the appropriate departments. Pre-coders then enter the key-in codes for insurance companies, doctors and modifiers. Pre-coders also add insurance companies, referring doctors, modifiers, diagnosis codes and procedure codes. The coding team assigns the Numerical codes for current procedural terminology and the diagnosis code based on the description given by the provider. The charge team has competent individuals who would first enter the patient personal information form the information given. Also they check for the relationship of the diagnosis code and the current procedural terminology. They create a charge, according to the billing rules pertaining to the specific carriers and locations. All charges are accomplished within an agreed turnaround time, about 24 hours. The daily charge entry then needs to be audited to double check the accuracy. Claims are filed and information sent to the transmission department. This department prepares a list of claims that go out on paper and through the electronic media. Once claims are transmitted, confirmation report are obtained and filed after verification. The carrier adjudication department would review the claim and after their edit checks, the claim would be adjudicated on and processed for payment. Cash application team receives the cash files and applies the payments in the billing. During this process, overpayments are immediately identified and necessary refund requests are generated for obtaining approvals. Analysis are a key to any group. They research for completeness and accuracy and work orders are set up for the call center to make calls. They are responsible for the cash collections and resolving all problems to enable the account. They also research claims denied by the carriers. The caller calls up the insurance and verifies if the claim is with the carrier and what is the current status of it. At the end of the month they run the Doctor Financials and other procedure code usage reports, aged summary reports so that momentum that has been achieved for that month, if not there would be a pattern of non-payment. Electronic processing and transfer of data is encrypted and password protected to ensure privacy and confidentiality. Dedicated leased lines and Firewalls ensure security of data. Confidentiality of patient and practice information is assured. Records are kept secure and all appropriate laws are observed for handling the release of information.