YOU’RE PART OF A TEAM

Chapter 2


YOU’RE PART OF A TEAM



Objectives


After completing this chapter, you should be able to:


image Relate three or more responsibilities of business office personnel


image Briefly explain how each business office employee influences medical reimbursement


image Discuss legal aspects for each business office position


image Relate three or more of the responsibilities of the clinical staff


image Briefly explain clinical staff responsibilities for documentation and how it influences reimbursement


image Discuss legal aspects for each clinical staff position



Key Terms



ancillary medical providers


professionals with a limited license to practice medicine and medical therapists who perform billable services.


billing manager


the supervisor in charge of medical billing and collections; may or may not include medical coding.


business office personnel


employees in the medical business office: office manager, billing manager, schedulers, receptionists, billers, collections employees, medical records employees, and professional medical coders.


certified coding professional


someone who has met the educational and experience prerequisites and who has passed a medical coding certification test administered by a professional coding organization.


clinical staff


the production employees in the medical practice: physicians, NPs, PAs, ancillary medical providers, nursing personnel, and technicians.


clinical support staff


the members of the clinical staff who do not practice medicine, although some do practice nursing: RNs, LPNs, technicians, CMAs, and RMAs.


CMA


certified medical assistant; an employee whose education places an emphasis on the outpatient medical office and encompasses both clinical and business office functions and who has passed a certification examination administered by the American Association of Medical Assistants (AAMA), a professional association.


collections employee


an employee with responsibility for collecting payments from insurance companies and patients.


credentialing


the process of verifying credentials to establish that a person has not misrepresented accomplishments, that licensure remains current, and that the person has not been excluded from participation in federal medical plans.


custodian of records


the employee who is legally responsible for the care and handling of medical records for the medical practice.


DC


doctor of chiropractic medicine; schooling focuses on medical health in relation to spinal alignment; fully licensed to practice chiropractic medicine.


DO


doctor of osteopathy; similar to an MD, but schooling places a larger emphasis on the role of the musculoskeletal system in overall health; a graduate from an osteopathic school of medicine who is fully licensed by the state to practice medicine.


FBI


Federal Bureau of Investigation; they investigate and prosecute federal offenses and criminal activity.


HIPAA


Health Insurance Portability and Accountability Act of 1996; a federal law that governs many aspects of health care.


LCSW


licensed clinical social worker; a limited-license mental health professional with a minimum of a bachelor’s degree and who has passed a state licensure examination.


limited license


the scope of medical practice has limitations; the number and the type of services are less than for a full license to practice medicine; often limited to a particular specialty and to specific services within that specialty.


LPN


licensed practical nurse; a limited-license nursing professional whose education places an emphasis on the clinical aspects of nursing and who has passed a state licensure examination.


MD


medical doctor; a graduate from medical school who is fully licensed by the state to practice medicine.


medical biller


a medical business office employee who prepares and submits medical claim forms.


medical records employee


a medical business office employee who is responsible for handling and safeguarding patient medical records.


no-show


a patient who fails to arrive for a scheduled appointment and who has not called to cancel the appointment.


NP


nurse practitioner; a registered nurse who has received advanced education and has passed a state certification examination to obtain a limited license to practice medicine in addition to nursing.


office manager


the top-level supervisor in a medical practice whose responsibilities encompass both business office and clinical duties.


OIG/HHS


Office of Inspector General, Department of Health and Human Services.


OT


occupational therapist or occupational therapy; requires a minimum of a bachelor’s degree and passing a state licensure examination to obtain a license in occupational therapy.


PA


physician’s assistant; a medical provider who has completed the required education and passed a state licensure examination to obtain a limited license to practice medicine.


patient-supplied information


the billing information for the top half of the medical claim form.


physician


a person who is fully licensed to practice medicine: MD or DO.


provider-supplied information


the billing information for the bottom half of the medical claim form.


PT


physical therapist, or physical therapy; requires a minimum of a bachelor’s degree and passing a state licensure examination to obtain a license in physical therapy.


receptionist


the business office employee who greets patients and obtains or verifies the patient-supplied information for the medical claim form.


RMA


registered medical assistant; an employee whose education places an emphasis on the outpatient medical office and encompasses both clinical and business office functions and who has passed a certification examination administered by the American Medical Technologists (AMT), a professional association.


RN


registered nurse; a fully licensed nursing professional. Must complete required education and pass a state licensure examination to obtain a license as a registered nurse.


scheduler


a business office employee who schedules patient appointments.


scope of practice


the legal limits of licensure or certification; the number and type of services that can be performed with a given set of credentials.


Security Standards for Health Information


a law that governs the security of electronic patient records.


ST


speech therapist or speech therapy. Requires a minimum of a bachelor’s degree and passing a state licensure examination to obtain a license in speech therapy.


vendor


a representative from another company that wishes to sell a product or a service to the medical practice.



Introduction


The rules, codes, and laws for collecting payment from medical plans and insurance companies are subject to change every year. Staying up to date and collecting payment is very time consuming. Therefore, physicians hire employees to perform these tasks.


National statistics reveal that medical offices hire an average of two full-time employees and one part-time employee per physician. That means about half the medical offices across the country have more employees per physician and about half have fewer employees per physician. Generally, one employee per physician provides clinical support and the rest work in the business office.


Every employee plays an important role in collecting and distributing information required for medical insurance billing. Clinical employees are held responsible for meeting some of the requirements and business employees are held responsible for meeting the remainder of the requirements for medical billing.


How well the team functions together to deliver and report patient services will be reflected in the payments received and will ultimately determine the overall success or failure of the practice. In a typical medical office, most of the payments are received from medical insurance companies and government medical plans, and just small portions of the payments are received from individual patients.



Business office personnel


Business office personnel run the business side of the medical practice, freeing physicians and clinical employees to provide patient care. In a large or very busy practice, multiple employees perform each business office function. However, in small single-physician practices, it is not unusual for a registered medical assistant (RMA) or a certified medical assistant (CMA) to be the only employee other than the physician. Therefore, it is important that every employee become proficient in medical business office duties. When you complete this course, you will have the educational background to fill any entry-level medical business office position.


Whether one person or many people are required to get the job done, each medical office position is very important and has unique responsibilities. Business office employees are responsible for collecting the patient-supplied information for the top half of the medical claim form, and they are responsible for processing the paperwork, submitting the claim, and collecting all payments due. One tiny piece of missing information can sometimes result in a payment of 30% or less of the amount rightfully earned by the physician, and sometimes no payment is received.


Many physicians sign insurance contracts that require specific actions from business office employees. Some insurance contracts specify who may treat the patient if the primary physician is unavailable; others specify time limits for scheduling patient visits and for filing claims, and some want specific language placed on the claim form. In addition, the physician usually agrees to accept a lower payment for each patient service. “Payment in full” usually becomes the payment amount listed in the contract, and it often includes the payment amount the contract states the physician may collect from the patient. Therefore “payment in full” for the same service may be different for each insurance plan. Collecting insurance information, filing claim forms, and tracking the results must be performed exactly as stated in the contract.


No matter how small or inconsequential it may seem, every piece of information that eventually flows onto the medical claim form is meaningful and every employee plays a critical role on the medical office team. Therefore it is essential that everyone learns about medical insurance and how to work together as a team.



OFFICE MANAGER


The office manager provides administrative oversight for the entire office. In larger practices, the title for this position might be the Practice or Group Administrator. The office manager is the supervisor for other employees in the medical practice, and he or she is the coordinator who ties together the clinical functions and the business functions so things flow smoothly. The organizational chart in Figure 2-1 shows the typical office manager’s lines of authority, although it may vary from office to office.


image
FIGURE 2-1 An organizational chart shows the official lines of authority. Medical practices differ from other businesses in that there are also informal lines of authority from physicians to employees not under their direct supervision. Physician-owners are voluntarily placed under the direct supervision of the office manager while retaining the power to hire and fire, to give directions to employees, and to make final decisions.

Office managers are responsible for employee management, business account management, insurance contract management, production manage-ment, document management, and patient account management. They do not have to personally perform each task, but they are responsible for seeing that each task is performed correctly. Only the owner(s) of a medical practice have more power, authority, and responsibility than the office manager. Let’s take a closer look at each of these responsibilities.


Employee management entails recruiting, hiring, firing, orienting, training, supervising, and disciplining employees. It is the office manager’s responsibility to learn the new laws, rules, and regulations that govern medical practices and to provide continuing education on these matters for the other employees.


The office manager sets an example for employees. If the office manager wears appropriate business attire, uses professional personal conduct, portrays high ethical standards, and shows that he or she values patients by treating them with the greatest respect, the other employees can be required to do the same.


The office manager is responsible for updating and enforcing the written policies and procedures of the practice. Regardless of who performs each task, the office manager is responsible for seeing that the task is performed correctly.


Business account management has four important duties:



Insurance contract management includes managing existing insurance contracts and analyzing new contracts to help physicians decide which contracts to sign. Each existing contract contains information other practice employees must know. The office manager is responsible for learning the details for each contract and distributing them to employees on a need-to-know basis.


However, physicians tend to misunderstand the antitrust laws that are intended to prevent physicians from engaging in price-fixing. Under the antitrust laws, physicians are not allowed to show their insurance contracts to other physicians. As a result, many physicians lock their contracts in a file cabinet and don’t share them with anyone.


Physicians are allowed to share insurance contracts with employees on a need-to-know basis. Employees must agree not to share this information with anyone else. Physicians also may share insurance contracts with accountants, consultants, and attorneys on a need-to-know basis. These professionals are obligated to keep the information confidential. They help the physician analyze contracts for profitability, for ease of meeting contract requirements, and for legal issues with insurance clauses. The office manager coordinates and distributes contracts or contract summaries as needed and meets with outside professionals who assist with contract issues.


The process of delivering medical care is considered production. Productivity management entails overseeing every practice function associated with delivering medical care. It includes many important duties:



Productivity management also requires the office manager to serve as a gatekeeper for the physicians in the practice. The time each physician spends providing medical services to patients are production hours that generate revenue (income) for the practice. The time each physician spends on non–patient-care tasks does not generate revenue. Therefore the office manager oversees management of physician time by supervising the screening of telephone calls and the screening of non-patient visitors for the physicians.


Most physicians request that only telephone messages that require physician action reach them, and they often want those to be prioritized by urgency. The physician, the office manager, and the employee who takes a telephone message can all be held legally accountable to the level of their responsibility for how a telephone message is handled in a medical office. Employee responsibility for taking messages ends when the action called for by a message is completed or when responsibility for the message is turned over to the office manager. The office manager’s responsibility for taking messages ends when the action called for by a message is completed or when responsibility for the message is turned over to the physician. However, many physicians appreciate follow-up reminders from the office manager until every physician-action is also completed. Documentation for some types of telephone messages should remain on file until the legal requirements for record keeping have expired. Record-keeping requirements vary from state to state, but are usually at least 7 years.


Nonpatient visitors are usually vendors (salesmen) for pharmaceutical companies (drug companies), software companies, medical supply companies, and office supply companies. Sometimes the office manager has the authority to make purchasing decisions. Other times the office manager filters the information so the physician can review summaries of each product and can make final decisions from a concise choice of suitable products.


Documentation management includes monitoring the quality of documentation and either appointing or personally serving as the custodian of records (see below). The legal requirements for medical billing are very specific, and only the level of service that is documented may be billed. Often a clinical employee is given the responsibility of monitoring the quality of documentation by checking to see if the medical record documentation for a given patient meets the legal requirements for billing each service indicated on that patient’s billing documents for that visit.


The custodian of records is responsible for performing or overseeing the following duties:



Patient account management entails six important duties:



Ultimately, office managers are held accountable for how physician services are billed, regardless of who actually performs the billing task. The “Fraud and Abuse” sections in Title II of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) state that managers and owners may be held accountable for false statements on medical claims if they knew or should have known that the statements were false. It is very difficult to prove that a manager or owner should not have known what transpired in the practice.


Depending on the seriousness of the charges, civil and/or criminal penalties may be applied. Civil penalties can include fines of up to $10,000.00 per occurrence for incorrect coding or medically unnecessary services. Criminal penalties for false statements can include imprisonment and forfeiture of property, both real estate and personal property. Fortunately, the Office of Inspector General, Department of Health and Human Services (OIG/HHS) representatives have publicly stated that they do not intend to target medical offices that can demonstrate an effort to comply with the laws.


There are three major professional organizations that office managers may join to enhance their skills:



Each of these organizations can help an office manager keep up to date with current laws. Some of them offer credentials that office managers and administrators can attain. Continuing education is often required to maintain credentials and keep them current.



BILLING MANAGER


The billing manager provides administrative oversight for the billing department and reports directly to the office manager. The billing manager ties together the functions of billing and collections so things flow smoothly. The billing manager does not actively oversee other practice employees who collect information that is placed on the claim form, but he or she does coordinate with the other departments. The office manager mediates any disputes between the billing department and another department.


Billing managers are responsible for employee management within the billing department, and they are responsible for most aspects of patient account management. They direct both insurance and patient billing and collections. It is their responsibility to determine how to handle “problem” collections. Let’s take a closer look at each of these responsibilities.


Employee management entails hiring, firing, training, supervising, and disciplining employees within the billing department. It is the billing manager’s responsibility to learn the new laws, rules, and regulations that govern medical billing and collections and to provide continuing education on these matters for the other billing employees.


The billing manager is responsible for updating and enforcing the written policies and procedures for the billing department. Regardless of which billing employee performs each task, the billing manager is responsible for seeing that the task is performed correctly.


Patient account management in the billing department entails at least five important duties:



Obtaining required authorizations sometimes falls under the billing department and is sometimes assigned to another business office department. Converting chart information into codes for placement on the claim form is sometimes assigned to the billing office and is sometimes assigned to clinical staff members. In addition, the billing manager is usually responsible for developing a variety of routine patient letters: welcome letters, reminder letters, “no-show” letters, and collection letters.


The billing manager directs both insurance and patient billing and collections. He or she decides how to divide up the billing and collection functions between the assigned employees, and he or she determines the methods to be used for problem collections. The billing manager enforces policies regarding when to rebill claims and when to file appeals.


The billing manager enforces policies regarding when and how often to send patient statements. Some contracts and some state laws have strict requirements regarding patient statements. When in-house collection efforts do not produce results, the billing manager determines which claims to send to a collection agency. Often physicians must give the final authorization before using a collection agency.


Ultimately, billing managers are held accountable for how physician services are billed regardless of who actually performs each billing task. The “Fraud and Abuse” sections of the HIPAA law state that managers and owners may be held accountable for false statements on medical claims if they knew or should have known that the statements were false. The rules and penalties are the same for all management employees.


There are six major professional organizations that billing managers may join to enhance their skills:



Each one of these organizations can help a billing manager keep up to date with current laws. Some of them offer credentials that billing managers can attain. Continuing education often is required to maintain credentials and keep them current.



SCHEDULERS


Schedulers are responsible for scheduling patient appointments. Once, this was a relatively easy task. A patient called for an appointment, and the scheduler penciled the patient’s name into the first available time slot that was convenient for the patient. Payment was always a patient responsibility and the patient sought reimbursement from his or her own insurance company.



STOP & REVIEW


For each management position in the left column, write the letter or letters of the corresponding duties listed in the right column.





Answer the following:




3. Professional organizations offer an opportunity to earn credentials, to learn about changes to laws, and to update skills.


    _________True_______False


4. Among professional organizations, there is one clear choice for office managers and one clear choice for billing managers.


    _________True_______False


5. Employee management includes:



6. Patient account management of the billing manager always includes obtaining authorizations for the services rendered.


    _________True_______False


7. Who is the direct supervisor of the billing manager?



8. Antitrust laws prevent:



9. Productivity management includes monitoring the flow of patients through the office.


    _________True_______False


10. Business account management includes preparing and submitting insurance claims.


    _________True_______False


In some medical practices, especially in areas that do not have many managed care plans, appointments are still scheduled in this fashion. However, more than 80% of the patients in the United States are now covered by managed care medical insurance plans. Astonishingly, more than half these patients—and nearly as many physicians—do not know the medical plans are managed care plans. All major insurance carriers, including most government carriers, now include managed care plans in the mix of medical plans offered. HMOs (health maintenance organizations) and PPOs (preferred provider organizations) are the best-known managed care plans. Chapters 8, 9, 10, and 11 cover medical insurance plans, including managed care plans, in more detail. Whether patients know they have a managed care plan or not, additional tasks must be completed at the time appointments are scheduled for these patients.


Only managed care insurance plans and government medical plans require a physician to sign a contract, and each physician is required to sign his or her own contract. Most contracts require specific actions when patients call to schedule an appointment. Therefore, schedulers today must be equipped with a list of the specific scheduling requirements for each medical plan contract and a list of each physician in the practice who is authorized to provide services under each contract. In addition, the scheduler must pay close attention to the rules for substitution coverage when the primary or authorized physician for the patient is unavailable.


The scheduler’s most important responsibility is to schedule patients only with providers authorized by the patient’s medical plan. The practice will not receive payment for services if an unauthorized provider sees the patient, and a provider excluded from government health plans could face fines of up to $10,000.00 per day for seeing government plan patients.


When you work as a scheduler and a patient calls for an appointment, you must first ask a number of questions to determine whether an appointment may be scheduled with the requested provider.



Related posts:

  1. DEVELOPING CRITICAL THINKING SKILLS: ANALYZING PROBLEMS AND MAKING DECISIONS
  2. REIMBURSEMENT SUCCESS
  3. OTHER GOVERNMENT MEDICAL PLANS
  4. HOSPITAL/FACILITY BILLING RULES

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May 25, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on YOU’RE PART OF A TEAM

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