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Medical Practice Management – Workflow Strategies

All successful management strategies start with a plan. Changing work procedures as you are going along, in a piecemeal basis confuses staff and creates chaotic work environment. Before introducing or implementing new work strategies, observe your practice’s daily routine. Take input from all staff, then make a plan. Draw out a clear diagram to guide you, the manager, doctors, and staff. A well-planned workflow diagram takes into account all tasks, big and small, performed in the office. It is a map that leads to successful management and increases productivity. Revisit your workflow diagram in intervals to make changes to better suite your practice needs. 

Before Visit

Phone Operator

  • Identify the patient’s needs.
  • Schedule patient for correct service and practitioner.
  • Collect full demographic information.
  • Collect all insurances information.

Billing Department

  • Verify patient’s insurance coverage.
  • Identify primary, secondary, and other payors.
  • Determine referral/authorization requirements.
  • Identify any Co-Pay, Co-Insurance, and deductible.
  • Make notes of all findings in patient’s file.
  • Inform patient ahead of visit date about any health/vision benefit issues which need to be cleared with insurance.

During Visit

Check-In

  • Verify patient’s contact information.
  • Verify insurances on file.
  • Scan in any new insurance card or referral into the system.
  • If patient has a balance, have a statement ready to hand over.
  • Collect any cost-share amount determined by the Billing Department.

Technicians

  • Be aware of patient flow and wait time.
  • Any patient waiting for more than 15 minutes should be attended to.
  • Briefly explain to patient which services will be provided for the visit.
  • Make proper handover to front desk for checkout and follow-up appointments.

Check-Out

  • Check for any existing appointment before creating a new one.
  • Let patient know what may be done at the next appointment.
  • Hand over appointment card to patient with your initial on it.
  • Review appointment detail with patient to confirm scheduled appointment matches with patient’s copy.

After Visit

Claim Scrubbing

  • Print out the appointment schedule.
  • Cross check open claims with schedule to make sure claims have been generated for all patient visits.
  • Review exam notes and claims for proper documentation.
  • Identify any billing and claim issues which need follow up.
  • Review all authorization/referral for validity.
  • Check Place of Service, modifiers, NDC codes, and insurance information on the claim form.
  • Check the insurance cards one more time to make sure claims are going to proper payor.
  • Know your payors –Maintain active list of payor rules, LCDs, insurance addresses, fax#, etc.

Claim Submission

  • Claims must be created and submitted within 24 hours of patient visit.
  • Submit claims electronically whenever possible. This way you have proof of timely filing. This way claims will get processed and paid faster.
  • If e-claim is not possible, try to get fax number for the insurance claims department to send claim.
  • If case you have to mail any claims, keep close track of the claims.
  • Claim Transmission Time:
    • Electronic transmission through clearing house – 3 working days
    • Fax transmission – 3 to 10 working days
    • Paper claims by mail – 10 to 20 working days

Claim Follow-Up

  • Review clearing house rejections, software rejections, and EOBs  (Explanation of Benefits) for non-pay claims every day. This should be the first thing you do before starting any other work. All issues should be resolved the same day you receive them.
  • Post all payments and review all postings.
  • Review EOBs (Explanation of Benefits)  to be certain that insurance is paying according to contracted rate.
  • Run end-of-day report to cross check payment posting.

 Reports

  • Generate Insurance Aging Report and follow up on any claims past 30 days.
  • Generate patient aging report,  send out statements and follow up on delinquent accounts.
  • Analyze production report to highlight strengths and obstacles in the practice.
  • Analyze monthly reports of rejections, pended claims, and unsolved issues.

Download Work Flow Diagram