Understanding Healthcare Business Processes and Work Flow

Understanding the unique duties of a medical practice manager is essential when considering this challenging and exciting career in healthcare.

Understanding Healthcare Business Processes and Work Flow for the Medical Practice Manager

A medical practice is a business, and with any business, the office manager must display professional management skills as well as an understanding of the company’s goals and workflow. Accounting expertise provides the business with information on revenue and expenses that help maintain daily operations and hopefully, turn a profit at the end of the month.

In healthcare, the medical practice manager’s role is additionally defined by the knowledge he or she has in medical billing and coding, insurance payer rules, compliancy regulations and healthcare reform, quality operations and measures, knowledge of A/R reports generated from practice management software and the importance of documentation entered or retrieved in the electronic medical record.

It is important to be familiar with the types of providers who operate small medical practices and large group practices.

The first type of provider is the Medical Doctor (MD) who is referred to as an allopathic physician. An MD practices in the community under a myriad of ranging from Allergist to Urologist. Regardless of the type of practice you manage, familiarity with all specialties is important due to the transfer of patients’ medical data for consultations, surgeries, referrals, and authorizations. The second type of provider is the Doctor of Osteopathic Medicine (DO). They are commonly referred to as osteopathic physicians.

Physician Assistants (PA), nurse practitioners (NP), clinical nurse specialists (CNS), and certified midwife (CNM) fall under the category of non-physician practitioners (NPP) and are eligible for reimbursement by Medicare and many other insurance carriers using their own individual provider numbers. However, in many instances, these NPPs provide services under the medical supervision of an MD/DO and bill “incident-to” under the physician’s provider ID number.

Physicians must personally be involved in the initial course of treatment and remain active throughout the treatment. An MD/DO is required to be in the same suite (within shouting distance) of the NPP who is caring for the patient “incident-to”. Managers should have resources at their fingertips to ensure staff is documenting and billing compliantly. Websites such as www.cms.gov/Regulations-and-Guidance can offer a lot of valuable information. Each NPP has specific job requirements and managers must make sure NPPs are qualified to treat in their state and follow the rules associated with their credential.

There are additional staff positions that support physicians in practice. For example, a practice may employ a registered nurse (RN), a licensed practical nurse (LPN) or a medical assistant (MA) and certain specialists may utilize the skills of a radiology technician (RT). Physical therapists (PT), occupational therapists (OT) and speech-language pathologists (SP) may work in a healthcare setting or independently and are state regulated. In addition to these physician supported specialists, there are other healthcare practitioners that treat patients such as audiologists, optometrists and opticians.

Certified nursing assistants (CNA) tend to work for home health agencies, nursing homes and hospitals. Home health aides (HHA) are professionals who assist patients in their homes.

The above mentioned health care providers work together to provide the best possible care for the patient and office managers must make sure that everything from care plan oversight documentation to referral authorizations are in place so that appropriate treatment is provided and reimbursement for services are paid timely.

Overseeing a practice’s workflow is not an easy task without proper training. Every employee in a practice has a specific job description that is connected to a patient’s well-being and practice revenue. The process is distinctive.

The first step in the care of a patient is the initial contact with the office and scheduled appointment. The receptionist should be helpful and efficient, gathering preliminary information prior to the visit. Upon check-in, the front desk should verify patient information, make a copy of the insurance card, and verify eligibility. This function is vital to the health of the practice. Although working the front desk is not a difficult task, this job tends to create the most problems in terms of practice revenue so communication with the billing office should be on-going. Insurance denials pointing to terminated coverage or improper patient data must be identified and corrected to maintain cash flow.

The medical assistant (MA) takes the patient’s vitals, reviews the health history and prepares for the physician to examine the patient. The physician creates a progress note to record the visit and documents this data in the medical record.

When the patient checks out, he will pay his co-payment and resolve any other financial issues with the front desk.

Once the medical record is complete, the coder will assign codes for the billing department or review the codes if the provider has entered them on an encounter form. The biller uses the information to submit to the insurance carrier for reimbursement. If the claim is transmitted without errors, the office will receive money for the services provided along with a remittance advice (RA) breaking down each payment per service provided. The payments are posted from the RAs and patients or additional payers are billed for the remainder of the contracted amount. Appeals and adjustments are typically acted on when a claim is denied and denial trends are monitored and reported to the office manager. Financial reports will also provide details the practice manager can use to provide support and training to those who are responsible for problems with reimbursement.

Medical practices are transitioning from paper documentation to electronic medical records and office managers find they are not only managing the flow of the practice but also the information entered into the medical record from appointment scheduling to the medical assistant’s data and lastly, the provider’s input. When all information has been checked for completion, the medical record is locked and ready for billing. Transitioning to the electronic medical record is not only disruptive financially; it also affects the mood of the physician and his staff during the learning process. Effective communication skills are necessary when working in difficult situations, involving proper responses to frustrated physicians as well as effective body language.

It is the goal of a medical practice manager to hire a core group of employees with a team mindset. Each team member should have clearly defined expectations from the manager and work to achieve positive results. Without accountability, repeated errors can occur and employees will find themselves out of a job due to continuous poor performance.

Managing a medical practice is both rewarding and challenging. Coordinating all operations of a practice is also critical, and aiming towards a profit is essential. Compliancy must be understood and carried out with payer contracts and federal and state regulations followed.

In short, a medical practice manager must effectively run an efficient office. He or she will be managing employees and inventory, working towards the best collection methods for increased revenue and utilizing online resources to remain current with coding and billing trends.

The Certified Physician Practice Manager (CPPM®) credential will verify you as a professional in the industry and training is provided by both www. as well as www.aapc.com.

Related Medical Practice Manager Content:

www.cms.gov/Regulations-and-Guidance
CPPM®: Online Practice Manager Training Course AAPC
Certified Physician Practice Manager (CPPM ®): A New Career Opportunity- Coding Certification