How the different members in a medical office work together, and what each one does.
There are two distinct groups of employees in the medical office.
The front office staff aren't licensed medical personnel. The back office staff (medical staff) are trained and licensed in nursing as medical assistants or nurses. There may also be lab techs and x-ray techs.
The physician or healthcare provider (nurse practitioner, physician assistant) is usually the owner of the medical practice and always the boss. The physician has the best interest of his practice and patients as his primary concern. They also determine the culture of the practice and the resulting interaction among the staff.
There may be 2 supervisors in the medical office: one for the medical staff, and one for the clerical staff. The supervisors and the doctor make policies that guide the employees on their job descriptions and office polices.
Members of the front office are the first to interact with patients. There will be policies on how the phone calls are to be answered and how the calls are distributed to the appropriate personnel.
The receptionist may make appointments when calls come in or transfer to an appointment clerk. The receptionist greets the patient and follows HIPAA (Healthcare Information Portability and Accountability Act) rules to provide privacy with all conversations and records.
The front desk staff will enter the patient's information into the electronic medical record. This will include complete name, date of birth, address and insurance information. The paper forms will be placed in a folder and made available to the medical staff for the patient's visit.
After all of the forms are completed by the front desk, the medical staff will take the paperwork and open the electronic medical record.
The medical assistant (MA) will take the patient to the exam room and obtain a detailed medical history and reason for the current visit. The MA has access to the patient's demographics that have been entered into the system - however, she will still verify the patient's name and date of birth.
The medical assistant will record the patient's vital signs and current medications. Height and weight will be recorded in the medical record.
The medical practice will have written policies on how this information is obtained and recorded. At each step of the patient visit, the patient's confidentiality is always maintained.
The nurse will review everything, then interview the patient for additional information. She will enter all of the information into the chart.
All the information gathered is now available to the doctor. She will review this information prior to seeing the patient. Usually the nurse will be with the doctor during the exam.
The doctor will record all of her findings and recommendations in the medical record. In some medical practices, the doctors will employ a medical transcriptionist to type the dictated reports into the medical record.
The doctor will perform any procedures that she and the patient agree upon. The nurse will add all of this information to her notes and record any supplies and medications that may be used.
The doctor and the nurse will add the ICD-9 (International Classification of Disease) codes to the chart so the billing and coding staff will have the correct information.
All the information that is entered into the medical record is needed for the medical and front office staff to perform the work necessary to complete the patient visit.
The doctor may order exams to be performed outside of the office, such as X-Rays or laboratory tests. The medical practice may be large enough to have X-Ray and lab facilities in the office. The orders will be entered into the medical record and the nurse will send the patient for exams or make arrangements for outside services.
There will be interaction between the nurse and the front office staff to verify the patient's insurance requirements for additional services.
If the patient's insurance requires prior authorization, the nurse will refer the chart to the prior authorization clerk and the coder, to gather the information required to obtain the authorization for the requested exams.
The patient may be sent to the checkout desk and then home while the authorization process takes place.
As the patient goes to the checkout desk, payment is collected for the co-pay and deductible. If a future appointment is needed it can be made now.
When the patient has questions regarding payment or needs to make payment arrangements the front office supervisor will be available to assist with this more sensitive area of the practice.
Even though the patient has left the office, work continues on her behalf to obtain prior authorizations and to perform the billing process, to receive payment from the insurance company.
The prior authorization clerk will review the medical record to obtain the necessary information to send to the insurance company. She will need to consult with the medical staff to verify the medical necessity information to justify additional exams for the patient.
The insurance company may request a letter from the doctor to prove medical necessity. The prior authorizations clerk will gather all of the information and give it to the doctor, so that she can write the appropriate letter to gain authorization for requested services.
The medical record will be sent electronically or by fax to the insurance company. When the authorizations are received the appointment clerk will make the appointment for the patient to receive the requested exams.
The authorization number will be faxed to the referral offices. The prior authorization clerk will record the authorization number into the patient's medical record.
The prior authorization clerk interacts directly with the coding clerk, medical staff and appointment clerk. This ongoing interaction insures that the patient will receive the exams that have been ordered.
The coding clerk will review the current visit and associated medical notes to verify the CPT and ICD-9 codes that are needed to complete the insurance claim form. The clerk has resources through the computer software and books that contain all of the codes to be used to communicate to the insurance company what services were provided and the diagnostic reason for the services.
When the coder has completed the ICD 9 and CPT coding process the biller or billing department takes over the insurance claim form work.
The biller verifies all of the patient demographics: name, date of birth, address, insurance ID numbers, the insured's name and additional information required for the form to be completed.
The biller reviews the medical record to determine if the visit was a work related injury or illness or another form of accident. If the visit falls under these categories additional work and information is required to complete the claim form.
The billing clerk will also add to the claim form any supplies or medications used for the patient. These charges are also communicated to the insurance company by additional codes through the HCPCS II (Healthcare Common Procedure Coding System). Charges and any payment are added to the claim form.
The biller will add practice information to the claim form. This will include the legal name of practice and address, the NPI (National Provider Identifier) number, taxpayer ID and date of the claim form.
Once the coder and biller are satisfied that the claim is clean, indicating no errors, it is submitted electronically to the insurance company or other federal or state payers.
Patients generally don't know that so much work continues after they've left the office!
The nurses and MAs spend time verifying with the prior authorization and appointment staff that the ordered outside services have been scheduled for the patient. The doctor holds responsibility to make sure that her patient is able to receive the exams that have been ordered.
When the reports are received by fax or electronic mail, the nurses read the reports and convey any critical findings to the doctor's immediate attention. Critical finding policies are set by the doctor.
The doctor or the nurse will contact the patient immediately to let them know about these findings and any action required.
For non-critical results, the nurse will follow policies to flag these findings for the doctor to review. Normal results may be charted for the next follow up visit. All of these policies are made by the doctor so that he can stay on top of exam results.
The nurses and MAs make certain that all reports are received from the outside exams. This may involve phone calls to other offices with request for results to be faxed.
Effort must be made to have great communication between offices and hospitals to confirm that patients receive the exams and that reports are available as soon as possible.
There are lots of hours of phone time for nurses and medical assistants. In larger practices, nurses are assigned to the phone lines daily. The receptionist will answer and then transfer calls from patients that request to speak to a nurse about an illness or a follow up question or to obtain prescription refills.
Often the receptionist will need to take a detailed message or have the patient leave a voice mail. The receptionist may have a recorded message or she must state to the patient: "if this is an emergency please hang up and dial 911".
Doctors are responsible and subject to litigation if a patient is in need of emergency care and is not instructioned to call 911.
Nurses and medical assistants must be able to make a decision, following the office policies, on how to handle each call. Patients that need to be seen are asked to make an appointment to see the doctor.
The largest volume of calls is for prescription refills. The practice will have policies regarding medication refills. The doctor will set the policy for refills to be in compliance with the DEA (Drug Enforcement Agency), state medical boards and state pharmacy boards.
Nurses will call in or fax refill orders to the pharmacies, and follow the policies and direct calls to the appointment clerk when a refill requires a visit to the doctor.
The nurses must enter all of these calls and refill orders into the medical chart. This time spent on patient calls is part of the office visit - no additional charges may be entered by the billing staff.
From the time an appointment is made the office staff interacts and communicates in an ongoing effort to provide quality patient care.
Interaction continues long after the patient has left the office. The doctor sets the tone or culture of the office staff in her method of communicating her policies to all members of the staff.
Without the medical office staff, the doctor wouldn't be able to do all the work required to receive payment from the insurance company. She is dependent on her staff, whether it's a two-member staff consisting of a receptionist and a medical assistant providing all of the non-doctor work, or a staff of 50. The number of steps to payment remains the same.
Interaction is not just verbal communication in a medical office. Interaction includes all of the work being performed and recorded by the entire team. The interaction throughout the entire team on a daily basis is essential to provide quality care for each patient.
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