Lessons

Between the time a patient walks into a medical office and is treated, what happens? Lesson 2 will show you this and other steps in the intersecting paths of patients, medical providers, and medical claims specialists.

The Daily Medical Office Professional Routine

Cindy is the office manager for Family Medical Clinic. This clinic has four doctors - Dr. Johnson, Dr. Lang, Dr. Garner and Dr. Olsen. Cindy is responsible for tracking patients as they arrive and check-in for their appointments. Each doctor will see about 15 patients today. Cindy's appointment book contains a different page for each doctor's schedule.

She begins with the 9AM appointments first. By 9AM, 4 of the 5 initial appointments have arrived in the waiting room. Two are new patients at the clinic, and are filling out the "New Patient Questionnaire" for the office. The other two are established patients. Barbara looks up and pulls out the medical files for each of these established patients. The medical files are thick manila folders that are coded on the tab according to the patient's last name. Then she prints an encounter form and paper clips it to their folder. She places these two files in the "Patients to See" stack for each doctor's nurse. One established patient is seeing Dr. Olsen and the other is seeing Dr. Johnson.

A couple of minutes after getting the files to the nurses, the two new patients bring up their completed questionnaires. Cindy spends the next few minutes creating medical files for these two patients -- one in the computer and one on paper. After she has entered the information about the patients on the computer, she tells the computer to print out an encounter form for each of them.

Cindy clips the encounter forms to the appropriate folders and then distributes them --- one goes to Dr.Lang's nurse and one to Dr. Garner's nurse.

It is now 9:00 AM. One appointment hasn't arrived yet.

At 9:04 Cindy receives a call from the missing patient. He has had car trouble and can't make it today. Cindy assures the man he can reschedule. As she talks to him, she opens the appointment book to Dr. Lang's pages. Dr. Lang can see him the next day at 9AM or the following Wednesday at 2:00PM. The man on the phone picks next Wednesday, and Cindy records the appointment on Dr. Lang's schedule.

By 9:07, all four of the other appointments are back from the examination. The 9:15 people start to arrive. They are all established patients, so Cindy pulls their files, prints out an encounter form, and distributes the folders to the correct nurses.

Now it is 9:10 AM and Dr. Olsen has finished with his 9AM appointment – a man named Jim Burgess. Mr. Burgess walks out of the examination room and carries the encounter form over to Cindy. Cindy looks at the procedures on the bill that the doctor circled and quickly fills in an amount next to each one. She totals the bill-- $187.50 -- and has Mr. Burgess sign it.

At Family Health Clinic, most patients are covered by an insurance that requires that the doctors office send the bills to the insurance company without the patient paying an initial co-payment or the entire amount of the bill. So Mr. Burgess just has to sign to give the insurance company permission to pay the clinic directly. Mr. Burgess signs the form and returns it to Cindy. She rips off the back copy for him and hands it back. As Mr. Burgess picks out a free lollipop from the basket on the counter, Cindy quickly files the completed and signed encounter form in her "To Submit, Current" file. Dr. Olsen's nurse has returned Mr. Burgess's file.

Cindy retrieves it and places it in the "To be Updated" basket -- the place where files that must have new action recorded in them are placed. When the transcriptionist gets done with the doctor's tape from this morning, the transcribed notes for Mr. Burgess will go in to Mr. Burgess's file. Then it can be put back with all the other medical files.

Cindy's day goes on like this from 9 AM until she leaves at 6 PM. During that time, she is continually checking-in patients, entering new questionnaires on the computer, creating files, retrieving files, completing encounter forms, and scheduling and rescheduling appointments.

Now let's take a look at the same activities from the perspective of the medical claims specialist.

Medical Claims Specialists Daily Routine: The Old Paper Method

Joann, the claims specialist for Family Health, deals mostly with insurance companies and patients who have already received treatment.

Joann starts the day by going through the claims that are still outstanding -- that is, bills that haven't been paid yet. For this clinic, 90 percent of these outstanding claims are still waiting for insurance payments. The other 10 percent are due either from patients who don't have insurance or from patients who need to pay the remaining portions of the bills that their insurance policies did not cover.

A few of the insurance claims are late in being paid, so Joann starts calling the individual insurance companies, trying to track down each claim. It takes two hours for her to work through the stack of ten claims. This type of follow-up is very important for the doctor's office. It prevents any claim from "slipping through the cracks" of the insurance world. After getting a better idea of when to expect payments for the claims, Joann files them away and goes to work with the individual claims (those that have a balance due from the patient).

Joann checks the individual claims for the time of notification -- how long it has been since each person received treatment. She marks those that are 60 days or more past due. These people will soon receive another reminder asking for payment.

Finally, Joann is ready to work on bills received during yesterday's clinic activity. In Family Health, the billing office is one day behind the reception area --- the medical claims specialist works on Tuesday's bills on Wednesday, Wednesday's bills on Thursday, and so on. Joann spends most of the remainder of the day checking encounter forms for correct diagnoses and treatments. She catches one where the doctor diagnosed and described treatment for a broken upper arm, but had circled cast for lower leg instead of cast for upper arm (the 2 descriptions are next to each other on the form). She makes the necessary change. Joann also checks the encounter form for complete patient information -- name, address, social security number, chart number, insurance company and policy number.

After making sure all the information is correct, Joann separates the encounter forms by arranging them according to each patient's insurance company. Medicare goes in one stack, Blue Cross in another and each individual private insurance company has its own stack. The claims, which will be based on the encounter forms, must be sent to the correct insurance companies – primary carriers.

The primary carrier is the insurance company that is billed first. It is primarily responsible for that patient's charges. There can be secondary and tertiary insurance companies. A secondary insurance company is billed after the primary carrier has paid its share of the bill. Tertiary carriers are billed after secondary carriers have paid.

After sorting through all the encounter forms and dividing them up according to primary carriers, Joann goes through each stack and removes the office copy of each encounter form. She files the office copies. Then she transfers the information on each encounter form to an insurance claim form, most commonly a HCFA-1500 form. You will learn how to fill out this form later on in the course. See the enclosed sample of a HCFA-1500 form

By 4:30 PM, Joann has organized, processed and packaged the claims she has gone through today. They go out to their respective insurance companies, and the clinic now can wait for payment.

Here are some of the important jobs as a medical billing specialist.

1. Gathering Information. As a medical claims specialist, you will gather all pertinent information. Usually this means using the encounter form (or other type of medical bill) to find out everything you need to fill out an insurance claims form.

2. Completing and Submitting the Insurance Claim Form. After checking the encounter form for accuracy, you then will use the bill to complete and submit the appropriate insurance claim form (usually HCFA form). It is very important to fill out the form correctly. Any error will delay reimbursement for either the doctor or patient.

3. Following up with Insurance Companies and Patients. After you have submitted the insurance form, you might need to contact the company regarding the claim. Because of this, it is very important you keep a copy of the claim so you can track down answers to any questions the insurance company might have. You might also have to follow up with patients to secure payments after the insurance company has paid its share.

4. Secondary Insurance Claims and Patient Billing. After the primary carrier has paid its share of the bill, if the patient has secondary insurance, you need to bill that secondary carrier. If the patient does no have secondary insurance, then the patient is responsible for paying whatever remains after the primary carrier has paid.

Note: As a medical claims specialist, you will have access to the medical records of many people. The records might be in the form of encounter forms, billing statements, claims or even, in some cases, complete medical files. It is essential that you understand that these records are strictly confidential. 

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