The reduction of accounts receivable is key responsibility of billing function in a medical practice. This article compares traditional (distributed) billing function with centralized workflow management. It shows that centralized workflow management yields significant advantages over the distributed approach in terms of the ability to manage accounts receivable. However, it also requires significant investment in process, technology, and personnel training.

Benefits of Centralized Workflow Management for Medical Billing

Centralized workflow management is superior to traditional billing operations management because it enables continuous billing process improvement and avoidance repetition of errors, while reducing dependency on specific individual billing knowledge. The billing process improves systematically along the key performance dimensions, including payment amount and its timeliness.

Centralized workflow management accomplishes such important benefits using a two-pronged approach based on formal encoding of billing and compliance knowledge and a computer program to apply the knowledge and manage claim followup lists.

As encoded billing knowledge base grows, the accuracy of the claims and the speed of the process increases. Additionally, the staff can spend more time focusing on exceptions, while an increasing majority of claims is processed automatically.

Moreover, centralized workflow shares its billing rules across all providers and billers. Therefore, errors discovered and corrected for one provider will be avoided in the future for all of the providers using the system.

What is Workflow?

Workflow is defined as a sequence of actions performed on a claim until it is paid. Centralized workflow management must quickly separate clean claims from potential failures, submit clean claims to payers, and flag potential failures for correction. Workflow must also track the correction process, ensuring its integration with other sources of failures and successful completion. Finally, workflow must facilitate meticulous documentation of every step to enable continuous improvement and learning from experience.

Failed Claim

A failed claim is a claim that is flagged by the workflow system upfront as an invalid claim, is rejected by the payer after submission, or is not properly adjudicated within 30 days -- in other words, a claim that requires followup.

Workbench

Centralized workflow manages such followup lists of failed claims using workbenches. A workbench is a list of failed claims assigned to individual biller or operator. Such individual assignment of work enables continuous and individual performance tracking and improvement.

Activity Triggers

In medical billing operation, the followup lists and to-do lists of individual actions for each failed claim constantly change. To manage multiple to-do lists, the centralized workflow system has activity triggers. Activity triggers are the heart of task automation; they help determine what's important. Activity triggers match up promises with events and manage individual work queues in the process.

Remembering to call a payer or a provider weeks after a phone conversation when payment or claim clarification was promised requires a billing clerk to sort through their call-on-receipt folder several times a day. Activity triggers eliminate the reliance on personal memory and enable communication between individual workbenches. They are the strings that tie billing activities together. When Mary from the providers office updates the claim with correct ICD-9, the system needs to be aware that the claim is ready for validation, and John in billing office needs to know so he can review it again, if the validation failed or schedule its transmission to the payer.

Task Automation

Centralized workflow eliminates paper-based steps. Like a relay team passing the baton, the billing staff members electronically pass along their work without delays. Instead of printing, faxing, and following up with an e-mail or a phone call, all tasks arrive complete with supporting documentation. Rather than thumbing through reams of paper reading scribbled notes, billers receive onscreen reminders when tasks are due.

Process Monitoring

Centralized workflow also simplifies process monitoring. Providers and managers use dashboards to review key indicators. Like activity triggers, dashboards help focus personnel on what is important from high-level perspective. They show key business information that tells us if we are paid more or less over time, if our charges are going up or down, and if our followup policies are too lenient. They tell us whether we are heading in the right direction and act like lighthouses to keep us off the shoals. When we see that warning light, we can drill into the details and take corrective action.

Summary

The key difference between vericle-like centralized workflow management and traditional approaches is that a centralized workflow guides the operator in terms of claims that need followup. There is no need to manually look up reports to analyze data and select claims for followup. Vericle-like approach ensures followup consistency and timeliness.