Outsourcing and Basics

Outsourcing and Basics: 

Outsourcing can be defined as defined as delegation of a Non-core activity of a business to a third party, who is specialized in that enabling us to concetrate on our core activity. For an example Maid-Servant.

Types of Outsourcing: 

1. Selective Outsourcing: It is where one part of business is selected and outsourced. Example: Marriage function: Catering, Decoration, Hall arrangement etc.

2. Total Outsourcing: It is where one business is devided and given to various third paries, get their end products and assemble as one finished product. For example Manufacturing of a Car, Mobile phones.

3. On-shore Outsourcing: It is where a business is outsourced within the country or within the boundary. For example Domestic call centers.

4. Off-shore Outsourcing: It is where a business is outsourced from country to country or from boundry to boundary. For example International Call canters.

Advantages of Outsourcing:

1. Cost-Effective Labour
2. Multi-Talented
3. Adaptability & Flexibility
4. Insfrastructure

Disadvantage of Outsourcing:

1. Quality

2. Productivity

3. Turn Around Time (Target time to complete a job)

Medical Billing:

It is a process of submitting & following up on claims with the Insurance companies to receive payment for the services renered by a hea;llthcare provider.

Duties of a Medical Billing Company:

1. We work for the Providers.

2. We bill to the insurance companies on behalf of the providers.

3. We make sure that all his bills are paid.

In short, Medical Billing is the Financial Data Management for the Providers.

                        Revenue Cycle Management (RCM)

The Revenue Cycle Management process flow clearly explains to us how the Financial Data Management for the provider is carried out. It gives us a picture of how we generate the revenue for the provider and is managed.

The RCM starts with the first entity which is the patient being classified in to "New" and "Existing".

A New Patient can be defined as the one who has not visited the provider's office at leat one in the past 3 years.

An Existing Patient can be defined as the one who has visited the provider's office at least one in the past 3 years.

Front Office:

This is the first place that the patient needs to go before they meet the provider. The Front Desk Executive will handover a form which is called as Buck slip or Face Sheet or Demographic Sheet to the patient to fill their personal details like name, date of birth, address and insurance details etc.

Provider's Room:

After the patient files their personal details on the Buck Slip, they meet the provider in his room and complain about their symptoms of the illness after which the provider will start his investigation to find out what the patient suffers from. This process of finding out the illness of the patient is called as "Diagnosis". Once the illness is identified, the provider then gives the appropriate treatment for the illness. The process of Diagnosing and Treating the patient is collectively called as Encounter.

Provider's Dictation:

After the patient leaves the room and before the next patient comes the provider dictates the diagnosis details and the treatment details of the patient he had met, in and instrument called 'Dictaphone' (technically a voice recorder).

Medical Transcription:

The voice file which is the Provider's Dictation is then sent to team called as Medical Transcription, where they hear the voice file which is converted into a readable text file as the 'Medical Record'.

Medical Coding:

The output of the Medical Transcription team which is the "Medical Record" acts as an input for the Medical Coding team where they read the medical records and code the illness or the injury with ans appropriate "Diagnosis Code" and the treatment given to the patient with a relative "Procedure Code' and the treatment given to the patient with a relative "Procedure Code". The coded medical record is then called as a "Charge Sheet".

Coding = Medical Records are interpreted into Diagnosis Code (Dx) + Procedure Code (CPT)

Demographic Entry:

The Buck Slips which are collected at the front desk of the Provider's office is later scanned and the scanned Buck Slips are sent to the Demographic Entry Team. The entry person first searches for the patient record in the provider's billing software with the name and the date of birth of the patient. If the patient record is found it indicates that the patient is an "Existing Patient". If the patient records are not found it is considered that the patient is a "New Patient".

Incase of an Existing Patient: the details on the Buck Slip is compared with the details in the software for that patient. If there is any new update in the Buck Slip like change of address, contact# or insurance policy details  etc. That will be updated in the software as well.

Incase of a New Patient: the details found in the Buck Slip are entered in the software and a record for the patient is created.

The function of Demographic Entry involves Creation or Updation of Patients Personal data.

Charge Entry:

The Charge Sheet from the medical coding team acts as an input for the charge entry team where they enter the charge details (Date of Service, facility where the treatment was rendered, name of the provider diagnosis codes and procedure codes) found in the charge sheet are entered in the software and is combined with the Demographic details to create a Claim, which is sent to the insurance company of the payments for the services rendered to the patient.

The function of Charge Entry involves entering of charge details with the combinations of Demographic details to create a Claim.

Claims Adjudication:

Claims Adjudication is a process at the insurance end, where they decided whether to Pay or Deny the claim based on the information found on the claim. If all the mandatory information are present and valid, the claim would be paid and if there is any missing or invalid information, the claim would be denied. 

Whether the claim is paid or denied the determination would be communicated to the provider through a document called as the Explanation of Benefit (EOB) or Explanation of Payment (EOP), which will be mailed out to the provider's office with their checks if the claim is paid. 

Forwarding of EOB and check copied from provider's office to the Billing Company:

The provider's office will receive the EOBs and checks from the insurance companies that they have billed, before sending the checks to the bank for clearance the EOBs along with their checks will be scanned and the scanned files will be sent to the billing company and the team which works on these EOBs and check copies is called the Cash/Payment Posting team.

Cash/Payment Posting:

Cash/Payment posting is a function wherein they will post the payment or record the denials in the respective Patient's account. If the payment for the services is received in full the account, the balance will be 'zeroed out'. Instead if there is a partial payment or the claim is denied, the record of all those claims are sent to the next level of team called as Accounts Receivable Analysis and Follow up.

The function of Cash posting involves posting of Payments or Recording of Denials with the help of the EOB.

Account Receivable (AR) Analysis and Follow up:

Account Receivable Analysis and follow up team is a function of the medical billing process, where they will analyze, follow up re-file corrected claims with the insurance company to resolve denied, underpaid and unpaid claims to get payment either from the insurance or from the patient to complete the Financial Data Management process.