Ideal Medical Practice Workflow

Written by on December 31, 2014 in Practice tips - No comments

8 Key Steps to Maximize Reimbursement

ClinicSpectrum would like to share with you our concept of “Ideal Practice Workflow” to increase your practice revenue and reduce costs.

MedicalStaffWEB“Workflow” is an engineering term meaning any series of steps, consuming resources, and achieving goals. More specifically, workflow is your organization’s series of steps, consuming your time, effort, and money, to achieve great clinical outcomes, satisfied patients, and maximum revenue and cost performance. In effect, workflow is the “user interface” between all the members of your team, between your team and your IT systems, and between your IT systems. The key to making everything work together, to achieve all three of your goals, is workflow, which is why we are absolutely fanatically obsessed with understanding, supporting, and improving your professional and practice workflow.

Let us analyze an ideal practice workflow and steps in engaging the patient effectively not only for clinical reasons but for financial reasons as well.

One! Appointment Call Received

Workflow begins with the patient appointment. When a patient calls to make an appointment, certain key parameters are essential to obtain over the phone for the success of efficient management of clinical and financial workflows. Key parameters include:

  • Patient’s Demographics
    • Name
    • Phone numbers
    • Date-of-birth
    • Gender
    • Insurance Company Name
    • Insurance ID for Primary and secondary insurance
    • Primary Physician if any
    • Reason for visit

The above items are essential to obtain over the phone in order to determine eligibility of the patient and define a preliminary care plan for the patient at the time of service. Patient information such as address, guarantor, work type, job and employer can be obtained when patient arrives in office.

This data drives and enables subsequent practice workflows.

Two! Eligibility Team Verifies Benefits

A back-office insurance eligibility team works on verifying eligibility of all patients depending upon his or her reason for the visit. Fast track or basic eligibility can often be verified using your Electronic Health Record/Practice Management System (EHR/PMS) but certain visit types may require calling an insurance company representative to verify detailed benefits and authorization and/or referral requirements. We recommend detailed telephone verification for all new patients. For returning or existing patients, the practice may use online or EHR/PMS options.

Depending upon eligibility verification, the back-end eligibility team creates a financial plan, including patient responsibility, and communicates to front office team for further action.

Three! Patient Check-In/Out

Upon patient arrival and check-in, information obtained during the phone call is double-checked, additional data is collected, and the patient is informed and educated.

  • Verify date & time of last office visit.
  • Update demographic information.
  • Update email and cell phone number.
  • Activate patient portal and email brief video tutorials.
  • Addresses alerts for financial and insurance issues.
  • Collect patient co-insurance, co-pay, and deductible.
  • Schedule next appointment upon patient’s check-out.
  • Confirm tests, procedures, referrals, and authorizations.

Again, as noted in the previous section on patient check-in and check-out, these data and activities drive and enable successful execution of many subsequent workflows.

Four! Pre-Physician Patient Engagement

Every minute a physician isn’t gathering information relevant to making future decisions (that no one else can gather), or actually making those decisions is a waste of a physician’s more valuable asset, his or her time, and directly reduces practice revenue. So far, we have covered the initial workflows of the patient calling for an appointment and checking in at the front desk. Just as those data and activities drive and enable important workflows, the data and activities of clinical assistants are even more important for great clinical outcomes, satisfied patients, and maximum revenue and cost performance.

Shifting as much work as possible, from the physician to the right nurse or physician/clinical assistant, can dramatically increase practice productivity. However, this is only practical if the right workflows are in place to make sure the work is done correctly and according to physician intentions.

Physicians should able to simply walk into an exam room, review patient information and decide whether tests and procedures completed by their clinical assistant team were truly necessary and if so, decide to bill them.

  • Validate primary reason for visit.
  • Take detailed history.
  • Confirm current meds taken by patient.
  • Documents allergies and current vitals.
  • Review clinical alerts.
  • Preventive tests based on conditions and treatments.
  • Document test & procedure medical necessity.
  • Execute relevant clinical protocols.

This workflow plan removes gaps in care plan management and improves risk management. This workflow helps in increasing medically necessary tests and procedures to avoid unnecessary referral and hospitalizations. In a nutshell, this is what we call “Accountable Care” wherein the clinical team truly follows clinical guidelines to take care of patients.

Five! Do What You Do Best: See Patients!

The physician walks into the exam room with a strong preparation done by his clinical assistants. She or he reviews complete history, allergy, and reason for visit, and completed tests and procedures based on clinical protocol. Physicians lose up to 40% productivity due to EHR “clickarrhea.” Therefore electronic chart is then completed through a hybrid workflow of dictation and/or Dragon-based speech recognition, and minimal EHR template clicks.

Six! Billing Team Generates Bill

After the chart is completed, billing information is transferred through via the electronic superbill to the billing team. Many practices submit claims in random order, disrupting cash flow. The following cycle of billing workflow is key to predicting ultimate cash flow.

The billing team should submit claims daily to forecast daily and weekly cash flow. They can maintain a gap of four days from date of service, providing enough time for physicians to finish charts, however the cycle of billing must be kept intact. Identifying gaps in billing and engaging patients for financial purposes is essential to your practice’s financial health. The billing team must follow a strict (but well-thought out) financial protocol-driven workflow. This workflow includes:

  • Submit claims daily for at least one day of service minimum (though some short gaps are allowed).
  • Post daily payments and bill balances to insurer or patients. Don’t wait for the end of the month.
  • Process denials within 72 hours. Keep them in work queue for follow up in 6-7 weeks.
  • Communicate to patients about high deductible, coordination of benefits, and health plan questionnaires.
  • Audit outstanding claims monthly and create action plans for follow up within six weeks.

Seven! Operations Team Finds Cost Reductions

The operations team, usually comprised of an office manager and key physicians in a practice, continually identify the use of technology or outsourcing to reduce costs. This team will conduct monthly meetings.

In our hybrid workflow model, tasks delegated to back-office team members result in savings of up to 30% or more.

Eligibility Verification
With high deductibles on the rise, proper eligibility verification is more crucial than ever. While about 60% of verifications may be completed online, detailed verifications for various procedures, and more specific templates customized to specialty, require a live representative call. Hybrid workflow allows a collaborative verification effort resulting in cost savings and decreased risk of claim denials.

Appointment Confirmation
Using a hybrid workflow model and outsourcing various tasks a practice can reduce significant operational cost all while becoming more efficient. Our automated engine schedules appointment confirmation calls, text messages, and email notifications, while the back-office team provides appointment confirmation for high value procedures through live representative calls.

Scanning and Indexing
EHR document management modules can receive in-bound faxes and compile scanned images, however those documents may accumulate over time and still must be indexed to the patient’s chart. This can be a time-consuming task. An outsourced back-office team can reduce the cost of indexing by 40% or more. The average cost of indexing per page or file done in-house is 50 cents. Outsourced it costs 10 to 25 cents per image or file.

Eight! Generate Clinical Reminders

The clinical reminders team data mines the EHR/PMS to identify patients for practice growth and required visits in office. They send reminders to patients through the patient portal, email, SMS, automated calls and live representative calls. The clinical reminders team encourages medication adherence and compliance for outside tests and referrals for patients.

Pre-visit preparations, to be completed 24-hours before patient’s arrival by outsourced back office clinical reminders team, include:

  • Look at problem list.
  • Last test and procedures.
  • Last lab results.
  • Last annual well visit.
  • Identify plan of care.
  • List clinically necessary procedures based on current problem list and previous assessment.

Evidence-based recalls, diagnostic tests and procedures, and annual wellness visits contribute to better patient care and risk management. This can increase revenue ten percent, or more, through additional opportunities for visits and in-office procedures.

The Ideal Medical Practice Workflow S.Y.S.T.E.M.

The above workflow plan can take a practice to next level in managing revenue, cost, and risk, making them truly accountable to you. After all, your system of carefully calibrated and systematically improved workflows should Save You Substantial Time, Effort, and Money.

With our innovative Hybrid Workflow Model, ClinicSpectrum helps medical practices, billing companies and other healthcare facilities reduce operational costs and increase revenue. Our Hybrid Workflow Model combines the best collaborative efforts to create efficiency in your organization.

By Vishal Gandhi, BSEE, MBA
Founder and CEO
ClinicSpectrum Inc.

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