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The role of the front office in reimbursement

By Mary A. Shaub, M.H.S

The role of the front office is critically important in the financial success of your medical practice. These individuals interact with your patients more than any other staff in the office outside of the physician.

As managed care concepts have dominated the health care market, the role of the front office staff has expanded from simply scheduling patient appointments, answering the telephones and pulling patient charts. Their responsibilities now include obtaining accurate patient and insurance information, collecting copays and deductible amounts, issuing and/or receiving referrals, precertifying certain surgical procedures and capturing and coding physician and nonphysician services. As such, the practice’s organizational structure must define job roles that incorporate financial functions.

There are six essential roles or functions in the front office. These are the office manager, a scheduler, receptionist, cashier, patient account representative and biller. Since many practices are confronted with budgetary restrictions that limit the number of support staff that can be employed, some of these functions may be combined into one job.

The office manager is the lead, supervisory position. This role includes patient and staff education. S/he insures that the staff can handle incoming telephone calls, patient requests and questions. It is his/her responsibility to insure that the patient flow is conducive to good customer service and maximizing collections. As the lead position in the front office staff, s/he must know how to perform all the other roles.

The receptionist must understand the patients’ financial and demographic information that is required for billing. S/he is the staff who will first communicate the financial policy to the patient. S/he will be collecting information for referrals and authorization requests. S/he must know the insurance plans the practice participates with and the participating status of the doctors.

The scheduler must know the correct method of scheduling patients for each doctor so that office time is efficiently utilized. It is important that s/he understands various insurance plans’ benefits, knowing when an appointment needs to have a referral or precertification.

The cashier will collect monies at the time of service. It is important to have a system that helps them to access present and past due patient financial obligations. It is critical that s/he knows how to read a capitation list.

The patient account representative will hold the role of patient advocate or financial counselor. S/he is responsible for educating the patient on the clinical and financial policies of the practice. This person will write referrals, obtain preauthorizations and enter registration and charge information in the computerized or manual billing system.

The insurance biller is responsible to make sure all services are billed with correct coding and on a timely basis, as well as paid accurately. This individual is responsible for training staff on CPT and ICD-9 coding changes.

How does this translate to the real world?

Let’s consider the structure of one inner city solo family practice with a patient base that is 90 percent Medicare. As of September 1998, the practice had not billed any services in eight weeks. How did this practice become financially viable within a four-month period so that a looming bankruptcy was avoided?

The office analyzed its customer service, patient flow and financial structures. Job descriptions were developed to incorporate financial functions. Forms to obtain accurate patient and insurance information were revised. Financial controls and reports were established.

The receptionist became trained in all the insurance plans and how to do daily Medicare billing. The patient account representative updated patient registration and insurance information. This person was responsible for updating patient information as well as verifying all insurances. The office manager established a financial policy, which included time-of-service cash collection procedures, daily bank deposits and payment posting, billing procedures, and establishing an accounts receivable report. This person also acted as the quality control point for patient concerns and patient flow. The part-time biller updated the superbill with current CPT and ICD-9 codes and assisted with the purchase of a computer that was able to accommodate electronic billing to Medicare.

The second scenario is a suburban family practice that increased capitation revenue by 22 percent and noncapitated revenue by 48 percent within a one-year period, from January 1999 through December 1999. First, the patient flow was redesigned. An automated telephone attendant was installed to address patient concerns more effectively. Decorative signs communicating office policy were placed on a bulletin board in the patient waiting area. “Change of Patient Information” forms were placed next to the sign in sheet. The practice developed a policy and procedure manual, which clearly outlined clinical standards, business standards including job descriptions and financial policies. This provided an objective tool that the office manager could train and manage staff and provide patient education on clinical and financial standards.

The biller researched past balances for the receptionist who collected these in conjunction with current copayments and charges at the time of service. Capitation lists were kept in files by the reception window so that the receptionist/cashier or scheduler/patient account representative verified patient eligibility. Patients, who were not on a capitation list, called their insurance from the front desk to choose an office physician as their primary care doctor. Referral information guides were developed for the scheduler/patient account representative. Insurance cards were reviewed at each visit after making the initial copy. The biller updated the superbill and devised a monthly accounts receivable report package. A daily account follow up form was developed and submitted weekly for review.

In both these cases front office staff insured that critical financial information was collected. Procedures, forms and monitoring tools insured that the patients received the best customer service possible. Below, I have summarized the relevant points, effecting financial success, which can be incorporated into your practice.

• Understand each staff’s role in the financial process and define it with a job description.

• Develop a financial policy. This will define your expectations to the patient from the beginning and serve as the financial standard for your practice.

• Review and update patient information. It is important to know where the patient lives, what their work and home telephone numbers are, where they work or go to school and birth dates (for pediatric patients, parental birth dates).

• Verify insurance information to determine eligibility and the correct submission location. It is important to have a complete identification number and to know if the patient is on a capitation list. Secondary insurance information, which is often overlooked, can increase reimbursement as well as influence the need for authorization of services.

• Prioritize the collection of copayments and annual deductibles. These can account for 10 to 20 percent of your practice’s noncapitated revenue.

• Understand the components of issuing or receiving referrals and precertifying or obtaining authorization. Not only will this promote good customer service, but it will improve the physician’s “quality of care/service” reimbursement from the insurance company and the processing of clean claims.

• Emphasize the correct coding and complete capturing of services. Correct coding, reflecting the current year’s coding changes, on charge tickets will promote timely payment.

As you see, the front office staff plays an extremely important role in the cash flow of the practice. These are exciting times in health care. The reimbursement puzzle is more challenging. With proper data collection tools, education and defined job functions, the front office staff can and will be a cash flow powerhouse!

Mary A. Shaub, M.H.S., is president of Shaub Medical Consulting, based in Philadelphia, Pa.

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