Basic Registrar Job

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Like a college Registrar, she answers the key question: How much will this cost me?

Reception has a hard time as Registrar...
Privacy and concentration needed for verifying insurance
Privacy needed to discuss care and payment plans.
The one thing the Receptionist does NOT have is privacy.

The doctor can often do it. Accounts manager or clerk can often do it.
Do it quietly and in private. This is the closest thing to a sales pitch we do.

Data Registrar MUST gather

...in general
a private place to meet
Office forms and policies
Acceptable payment guidelines


....with receptionists help
proof of identity
medical history
insurance contact
Verify insurance

....with doctor's help
today's fees
treatment plan
future fees

Forms you MUST address with patient:

HIPAA

release of records TO your office.

Permission to share information with their insurance

Insurance Verified

Payment plan summary and promise to pay.

Agreement to treatment (informed consent)

Type specific documents: WC827, PIPA, referral, pre-authorisation.

The first payment.


Last pass the data off to accounts to enter into the billing system as part of the day's traffic.
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All the best to you and yours.

Account Audit Procedure

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Below is a very complete audit procedure. You don't always have to do every step, but if the step you are on is just not making sense, go back and fill in the missing steps brings clarity. In my consulting work, this is mostly what I do.

Claim Audit

How to audit summary:

• 4 preliminary steps: Which account, posting & filing backlogs, ledger clean.
  
• 4 checks: service delivered, patient co-paid, claim sent, insurance replied
• 4 results: Paid Fair, Paid Poorly, No Payment, No Answer
• 4 actions: Patient collect, re-bill, write-off, defer

Four answers only every charge on the ledger

They paid a fair amount =
Correct coding, correct claim reading, fair benefits, correct identification.
To Do: bill patient co-pay and/or write off the balance.

They paid a poor amount. =
Incorrect coding, payer misread the claim, token benefits
To Do: Analyze and correct the reason for poor payment.

Paying nothing =
Incorrect identification, insufficient proof of service, no insurance or exhausted benefits or deductible
To Do:

No EOB:
wrong insurance, lost, not billed, or too recent for payment.
To Do: call to verify coverage and billing address and claim status, send or re-send the bill, or defer action.

Insurance Review Procedure

This post sponsored by
Common Ground Chiropractic Center.
2927 NE Everett Street, Portland, OR 97232.
503-232-4099 commongroundpdx.com

Accounts Receivable Aging

An aging report is a list of customers' accounts receivable amounts by age. The report is usually divided into columns of 30-day increments such as 0-30, 31-60, 61-90, 91-120, and 120+. It alerts management to any slow paying accounts. AR the main tool a collector uses to identify what accounts need attention and action.

Here is a sample AR report from a printer. (instead of patients, they have suppliers) It shows the key data: who owes money, how much, and when is it due. Some are simpler, some are more complex. If your computer system doesn't produce Aging Reports for you, first call your billing software tech support. AR is such a basic tool that every account management software system should have a useful one.

One warning about AR, though...

If charges, billing, payment and write-off posting are backlogged,
your Accounts Receivable and Aging will be false.
Handle your posting first.

If your patient and account filing is backlogged,
your charts and EOB's will be unlocatable.
Handle your filing first.

Now you can print and handle your AR report.

There are four main types of insurance: Group, Auto Injury, Workers' Comp, and Government. You don't have to do all of them at once every month. For example, in one office, each Tuesday I look at the AR for one type of insurance account, and rotate through the four types each month. In large or specialty practices, one type might represent most of your accounts, and take weeks to go through at first. Some types take only a few minutes to review, so double them up. Adjust your schedule and staffing to accommodate the needs of your practice.

On the day you regularly schedule to address your overdue accounts, catch up on your posting and filing, then print out the "AR by insurance type" for the types you need to review today. Printing this on reused paper is fine, since no one is going to look at it but us.

In Oregon, Insurance companies have 60 days to pay or deny a claim. Add in a little time to write up the charts, post the charges, send the claim, and get the reply, it is realistically about 75 to 90 days (11 to 13 weeks, three months) before you can even consider insurance money "overdue." The more recent stuff, you can work on it, but there's going to be a lot of "yes, we have it... we're still processing it" results that will waste your time. Adjust your schedule if your state rules are different: some states allow only a 30 days processing time. But in Oregon,

Any insurance 90+ days owing needs action.

Quick, highlight every account with 90+ days owing claims on it. Those are the ones to address.

Claim Review

Review is a short action, taking no more than 6 minutes with an account.

1) Scan the overdue account to locate the exact charges that are overdue

• a) Look at the individual account ledger.
• b) Unpaid charges are marked different ways in different software... learn yours.
• c) Find the oldest unpaid amounts and come forward in your work.
• d) Those old unpaid charges should about equal the amount overdue.

2) Each overdue charge gets a separate handling: Open the account file to see the EOBs.

• a) if it's not billed, or if you have no EOB, bill it again, or
• b) if nothing is paid at all, call to verify insurance.
  
• c) if you already re-billed, and it's overdue, no reply again, call to verify insurance.
• d) if have an EOB in reply, read the EOB, and decide what to do

3) Decide what to do and do it. The action is usually one of these:

• a) write off what you must and bill the patient what's fair now.
• b) send a corrected claim with additional data, notes, or authorizations
• c) contact the insurance to clarify their reply, then act.
• d) flag the account for a more complex handling. (this is really rather rare)

4) Write what you did so you won't needlessly repeat what you did next month.

• a) keep your notes in the patient account file.. they will help you later
• b) find where you can keep account notes in the computer billing system... and use it.
• c) Mark off your AR list that you handled this account.
• d) Use a tickler file entry for any follow up you need to do soon.
  
• e) Put away the patient file.
  

As soon as you are done with one claim review, go to the next claim on the aging list and handle it until you get to the end, and the project is done til next month. Sometimes, though, the account is too complex to sort out with a short review. Those need an Account Audit... in another article here.

If your aging list is very long and needs lots of attention - more than you can give it today or this week - target the largest accounts first and handle them. Then go for smaller accounts next time. Or target by insurance company names in order (A-M this time, N-Z next time), or by patient names. Whatever works for you.

In a few months, this job will become smaller, since you will have most claims running smoothly, with notes in the paper files, computer files and tickler file. But you will always need to do this one last step:

Schedule when to go back to this job next month.

All the best to you and yours, Gary

This post sponsored by
Common Ground Chiropractic Center.
2927 NE Everett Street, Portland, OR 97232.
503-232-4099 commongroundpdx.com

Deciphering an Explanation of Benefits

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Reading an Explanation of Benefits

• Commonalities and Differences
• Adjustment codes
• Missing EOB

Anyone who handles payments in a chiropractic office will, sooner or later, need to look at one of those confusing insurance payment explanations and decipher it. Every insurance company has their own form and style, and wordings and reasons for what they pay...or do not pay.

They even call them different things, like "Remittance Advice", "Explanation of Benefits", "Explanation of Review", "Claim Summary"... and I'm sure they'll invent more names and styles. All they are doing is tell you what they are paying and why or why not.

Here's the trick: there are only a few real things the EOB tells you:

1. Summaries: totals, subtotals, check amounts, disclaimers.
2. Identifying data: patient and doctor names and ID's,
3. Claim data: date of service, CPT codes, billed amount.
4. Reply data: payment amounts, non-payment amounts and reason codes

Most of this is easy to figure out, except the part you most want to understand: #4
Making errors in 1, 2 or 3 are a little silly, but totally possible: confusing one patient service date for another, or a summary for a payment can slow you down. After you check those, though, here's the meat.

Since everyone has to deal with Medicare, and Medicare "Remittance Advice" forms are the most complex, we'll use Medicare as the sample:


***insert more here*****

You do not have to know all the "reason codes" that payers use. Payors don't always use codes, and when they do, they always write out what those codes mean on the explanations. While Medicare dictates a list of reason codes, Medicare payors still have to write out what those codes mean on the claim form. But here what you really need to know..

THE REASONS THAT PAYORS GIVE FOR POOR PAYMENT
RARELY TELL YOU HOW TO FIX THE CLAIM.

Insurance carriers have to follow pages and pages of rules

Insurance Key Words

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Keywords and Concepts:

• Insurance, Benefit, Premium, Payor, Underwriting
• Deductible, Co-Pay, Maximum, Out-Of-Pocket, Usual & Customary
• Benefit, Assignment of Benefits
• Provider Types: Preferred, Participating, MMO, Referral, Primary Care
  
• Primary Insurance, Secondary Insurance, Third Party Insurance
• Personal Injury, Major Medical, Worker's Comp, Group Insurance
  
• Diganosis, ICD, Procedure, CPT, Pre-existing condition,

Insurance Collections Outline

This post sponsored by
Common Ground Chiropractic Center.
2927 NE Everett Street, Portland, OR 97232.
503-232-4099 commongroundpdx.com

Gary Shannon here.

This is a linked list of articles on Insurance Collections in this blog

These articles in outline form as of October 2010.

Sign up to this blog to get a copy any of them as they are written.

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Keywords and Concepts:

• Insurance, Benefit, Premium, Payor, Underwriting
• Deductible, Co-Pay, Maximum, Out-Of-Pocket, Usual & Customary
• Benefit, Assignment of Benefits
• Provider Types: Preferred, Participating, MMO, Referral, Primary Care
  
• Primary Insurance, Secondary Insurance, Third Party Insurance
• Personal Injury, Major Medical, Worker's Comp, Group Insurance
  
• Diganosis, ICD, Procedure, CPT, Preexisting condition,

Reading an Explanation of Benefits

• Commonalities and Differences
• Adjustment codes
• Missing EOB

Insurance Verifying

• Workspace: Phone, on-line.
• Key Questions
• Record Keeping

Insurance Audit

• 4 steps: service delivered, claim sent, patient co-pay, insurance benefit
• 4 results: Paid Fair, Paid Poorly, No Payment, No Answer
• 4 actions: Patient collect, re-bill, write-off, or defer

Rebilling tricks, simplest to most complex

• New Claim & Repeat Claim
• Tracer
• Corrected Claim -change in code or diagnosis
• Send additional charts and data (PIPA, WC827,
  
• Primary/Secondary EOB
• Phone call. Anti-duplicate
• Payor Recourse: Supervisor Intervention, Complaint Department, Review
  
• Other Recourse: State Complaints, Dispute Resolution, Employer Intervention,
  

All the best to you and yours.

This post sponsored by
Common Ground Chiropractic Center.
2927 NE Everett Street, Portland, OR 97232.
503-232-4099 commongroundpdx.com

Avoiding an IME

This post sponsored by
Joseph Medlin D.C.
Spine Tree Chiropractic
1607 NE Alberta St,
Portland OR 97211

IME stands for "Independant Medical Examination". You might correctly think of it as "Insurance Mandated Ending" to the case. I overheard Dr. Medlin tell another doctor about IME's and case management. He got it exactly right. I think:

Once your patient gets summoned to an IME, it's very very difficult to achieve anything further for the patient. A rebuttal is an option, but they will undoubtedly ignore it.

What I have found to be the most successful approach is to avoid the IME all together. Many times this can't be done, but with good notes on progress and a good causal narrative in the beginning and a good treatment plan showing improvements etc. with a defined and confident prognosis, the IME will be less likely. Also I've found that maintaining a good relationship with the case adjuster/mgr etc, does wonders to keep them off the IME button.

I'm not saying you didn't do any of this. It's not fool proof. I'm just providing what seems to work for me.

We staff can assist the doctor on this in several ways:

• Relay whenever a patient tells you about progress so the doctor can chart it.
• Always call to verify new Worker's Comp and Auto Accident claims.
• Learn the adjuster's name and preferred means of contact
• Ask if the carrier needs pre-authorizations or referrals
• Help the patient stay on schedule so they get better.
• Always send legible chart notes with the claims.
• Reply to questions about treatment plans quickly and sensibly.
  

All the best to you and yours!

This post sponsored by
Joseph Medlin D.C.
Spine Tree Chiropractic
1607 NE Alberta St,
Portland OR 97211

The Basic Receptionist

This post sponsored by
Common Ground Chiropractic Center.
2927 NE Everett Street, Portland, OR 97232.
503-232-4099 commongroundpdx.com

Gary Shannon here.

Receptionist

is the smiling face that greets every patient and doctor and staff. The idea is to:

bring the doctor, the patient and the papers together so that chiropractic care can occur.

This is an entry level position for a cheerful person who can tolerate stress and traffic.

Here is a the job description:

~~~Establishment:
(This is really the boss's job to train you, but you must take this in hand.)

• Locate and create a working space with room for files and tools
• Learn who does what jobs and how best to reach them when alone or with a customer.
• Learn your office preferred greetings, style and tempo. Examples:
1. "Hi, I'm Jill at Best Chiropractic. How can I help you?"
2. "When did you last see the doctor?"
3. "Would a morning or afternoon appointment be better for you?"
4. "I've got your appointment at Monday at 3:00 pm."
5. "Did I make a mistake?"
• 
  

~~~Communication & Arrivals:
(this part of the job is common to receptionists for many professions.)

• greet, answer, screen and route phone calls and visitors
• receive, sort and route mail and deliveries
• take and relay messages, faxes, e-mails and other communications
• provide information to callers and customers
• greet persons entering organization, help them sign-in for their visit.
  
• give and collect necessary paperwork to the customer
• provide a pleasant wait when necessary
  
• send files, notes and charts to the service provider
  
• direct arrivals to the correct destination
• get and send completed service records to be posted.

~~~Scheduling

• Create and maintains scheduling records and backups
  
• keep accurate schedule and status of working staff
• schedule and re-schedule customer appointments
• maintain the schedule book, manually or electronically
• make regular* follow-up with appointments needing to be made
• organize and support meetings, gatherings and events
  
• make and/or confirm new appointments for those leaving the office
• general administrative and clerical support
• prepare letters and documents

~~~Cashier:
(Parts of this job are shared with the Accounts Clerk)

• Collects per visit payments and co-payments
  
• Verify insurance coverage, requirements and permissions
  
• Daily, post all charges and payments and reconcile them
• Prepare and deposit money to the bank
• File payment and treatment records
• Back-up computer records relating to you job and use them as needed

~~~Promotions and Public image
( Even if there is a Office Manager handling "promotions", Reception is key)

• Be and make a good first impression
• Help other staff keep a productive and effective schedule
  
• Tidy and maintain the reception and public areas regularly*
• Encourage clients in their choice of your office
• Assist with word-of-mouth marketing and referral programs
• Encourage relative strangers to visit your facility
• Help other staff maintain a cheerful professional attitude
  

~~~ Backlogs & Special Projects:
(Will vary from office to office and time to time. Examples:)

• Locate patients who dropped off care last year and write a card
• Review appointments and sign-in sheets back 52 weeks and see charges posted
• Make new sign-in sheets with interesting pictures and messages
  

*"REGULARLY"

Your office lead receptionist (or office manager or owners) sets your follow-up schedule. "Regularly" differs from office to office. I use this schedule for "appointment needed" contacts:

• Missing co-worker: 5 minutes
  
• Missing patient: 15 minutes
• Second call to patient: 3 business hours
• Third call to patient: one day
• Fourth call to patient: three days, with written note or letter
  
• Fifth call to patient: one week.
  
• Sixth call to patient: three weeks, with written note or letter
  
• After this, let accounts and news-letters keep in touch
  

If your system allows it, schedule your next missed-appointment and never-made appointment calls on your master schedule. Then initiate them. Out-flowing welcoming communication is the central way the Receptionist helps your practice flourish and your patients improve.

All the best to you and yours.

This post sponsored by
Common Ground Chiropractic Center.
2927 NE Everett Street, Portland, OR 97232.
503-232-4099 commongroundpdx.com

Verifying Insurance - in progress

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Dr. Ed Hacmac D.C. has requested this article. Look for it soon.

Content to include:


Why you do not let patients do this for you.

Publish Post

Workspace and set-up

Private. Phone. Prepare to be on hold. Tues through Thu, 9 am to 3 pm.

Computer access is becoming more and more helpful. although carriers' websites are still not likely to answer the questions you must ask when verifying chiropractic care.

Make a verification form so that every thing you need to know gets verified. You may keep it internal or share it with your patient as you see fit.

The disclaimer.

Identifiers: Yours: Tax ID, NPI, phone number, address, or online log and password
Have these to hand in the work space.

Identifiers: Patients: Name, ID number, claim number, birth date, Group,
copy the insurance card, front and back. Copy photo id with birth date. Driver's license is ideal.

Key questions:

Jane would like to know if your plan covers chiropractic care at our office.

Does Jane need to file any documents to apply for benefits?
Typically, Auto accident victims must provide an application fro PIP benefits, a recorded interview with a claims examiner, or both. Injured workers must file the claim as well, either newly (in a WC 827 form) or as a transfer patient who was seen elsewhere.

Is this plan connected to a preferred provider group?
~~If so, is our doctor in the group?
When in doubt, get both benefits.

Do you require a pre-authorization or referral for benefits?
~~If so, who should I contact to get one?

Is coverage current and available now?
~~if a denied or exhausted injury claim, is there an attorney on record?

Benefits summary

This is the part you CAN find online... and the claims agent is well-trained in answering:
Warning... the answers can be complex and contradictory.

~What are the benefits, co-payments, and deductibles?
~When do benefits exhaust? How much as been used?
~Are there daily or yearly limits to care?
~Are there any exclusions to scope-of-license care,
~~~such as therapy, orthotic equipment or massage?
~To what address should claims be sent? E-billing number?

Ending wrap up.

Is there another insurance that may cover this patient according to your records?

Your name and a reference number for this call?

Sample form:

Basic Collections Job

This post sponsored by
Common Ground Chiropractic Center.
2927 NE Everett Street, Portland, OR 97232.
503-232-4099 commongroundpdx.com

Gary Shannon here.

Collections Clerk, Accounts Clerk, Billing Clerk

are names for an entry level position for someone with a head for details and figures. Their idea is that we know where and when every penny owing to the office will come from. This is the job that makes that possible by taking the time to keep good records and send out good communications about what we need paid.

Here is a the job description:

~~~Establishment:
(This is really the boss's job to train you, but you must take this in hand.)

• Locate and create a working space with room for files and tools
  
• Locate old and current service, price and coding lists.
• Locate all patient and insurance record file caches.
• Locate all computer billing programs and passwords.
  

~~~New Patient Accounts:
(For every new patient customer, make a basic account. )

• Verify insurance coverage, requirements and permissions (shared with others)
• Input patient and insurance information to billing system
• Verify and record patient payment plan
• Input diagnoses and procedure codes to billing system
  
• Tickle accounts for 60 day review

~~~Billing cycle: (shared with others)
(You share some of these duties with the Receptionist, but you see that it's done completely.)

• Daily, post all charges and payments and reconcile them.
• Prepare and deposit money to the bank.
  
• Locate un-posted charges and post them
  
• Produce claim forms and statements regularly* by type
• Produce recieveable lists regularly* and audit them.
• File payment and treatment records.

~~~Accounts Audits:
(This part requires organizational and detail-oriented skill:)

• Create and maintain a tickler/reminder collections system
  
• Query unpaid first visit charges after 60 days
• Query other unpaid insurance charges after 90 days
• Query unpaid patient charges after 30 days.
• Query legal and settlement accounts, provide data.
• Provide what non-payers need to pay the claim., such as notes and bills.
• After queries, make a tickler card for follow-up.

~~~Accounts Repair:
(This part touches on what an Account Manager will handle.)

• Locate faulty charges and claims and repair them
• Locate partially or un-posted payments and repair them
• Locate partially and unpaid insurance claims, and repair billing
• Locate long un-collected charges and repair or write off.
• Back-up computer records relating to you job and use them as needed.
  

~~~ Backlogs & Special Projects:
(Will vary from office to office and time to time. Examples:)

• Locate missing pre-authorization needed claims from last year to present
• Review appointments and sign-in sheets back 52 weeks and see charges posted.
• Shred the 10 year old patient files, but not children's files.
  

*"REGULARLY"

Your office account manager (or office manager or owners) sets your audit and account schedule. "Regularly" differs from office to office and account type to account type. I use this schedule:

• Tickler system: every day
  
• Flagged and Buggy Accounts: every three days
• Personal Accounts: every month.
• Insurance Accounts: every four to six weeks.
• Dual Insurance Accounts: every 10 weeks.
• Attorney Accounts: every three months.
• Barter Accounts: every four months.

All the best to you and yours.

This post sponsored by
Common Ground Chiropractic Center.
2927 NE Everett Street, Portland, OR 97232.
503-232-4099 commongroundpdx.com

Chiropractic Assistant Training

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The Chiropractic Aide

Gary Shannon here.

I've aided chiropractors since 1985 now. I've learned a few things along the way. It's time for me to share them.

Why The Chiropractic Aide?

"Chiropractic" means "using hands" (from Greek). Rarely using drugs or surgery (the two main tools of the American Medical Doctor), Chiropractic Doctors find and fix physical problems related to the body with hands-on methods. Doctors of Chiropractic have been though years of training, similar to Medical Doctors. They generally know exactly what they need to do to help patient achieve better health and better life.

In all that schooling, though, there are a lot of details about running a fun, effective office that chiropractic colleges do not teach. Thus,

DOCTORS ARE NOT TAUGHT HOW TO:

• run all the elements of a efficient practice,
• take on staff legally and efficiently,
• train and teach staff how to do their jobs,
• to help staff to work together (the doctor included),
  
• to work well with other professionals,
• repair administrative and personnel problems when they occur.
  

Doctors are motivated and smart. They generally only need a little training and guidance, then they "get it". These points are not part of the usual doctor curriculum. A lot of doctors do find out this stuff. A lot of it. A lot of them. Not all of them. Not all of it.

The Aide

That's where I come in. I have learned this stuff, through formal training, careful study and decades of experience. Thus I do consulting and contract work here out of Portland, Oregon. Based on my reputation, Chiropractors have contacted me for help and advice with all kinds of situations, big and small, wanting to know "how to" and "what to" and "can you". Then I give them the answers and solutions and techniques that they need.

This blog, then, is the course that chiropractor's didn't get while they were in college. Even chiropractic assistant training and office staff training doesn't generally include this stuff. After a while, I suppose I'll turn this into a text-book or something. For now, though, it'll be a more or less randomly organized set of essays about the details of a well-run office. I'll post the best comments. I'll update links. I'll add posts as time and demand allows. You can use is as you wish.

Disclaimer: You know your position a lot better than I do. If any thing I write here doesn't fit your experience or situation, don't use it. If you want something here clarified, corrected, amended or edited, please ask. I'm not hard to contact.

All the best to you and yours.