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Prevent service mistakes with root cause analysis

The Doctor's Office, May 8, 2008

The most common office problems—many of them billing issues that can frustrate patients—can be traced back to failure to perform one of five tasks. Create policies to ensure that each of the following five steps takes place automatically:

1. Verify the patient’s current healthcare insurance coverage. For example, the patient may have changed jobs and returns to your practice later in the year with new coverage. The front desk staff assumes the old coverage is valid and does not ask for the new card. As a result, the insurance claim form is sent to the old insurance and is denied. The claim then becomes the patient’s responsibility. The process to finally get the denial from the correct insurance can take months. And often, the patient will get a bill in the mail that he or she is not expecting but is required to pay. This can result in a very dissatisfied patient calling the doctor’s office expecting an explanation. Even worse, the patient may leave the practice and find another doctor.

2. Capture the complete and correct list of all procedures performed. As more and more practices have EMRs, the procedures/services performed for the patient are not captured. For example, a patient receives an immunization during one visit that was never captured and may receive the same immunization on a subsequent visit. This may cause health problems and make patients unhappy.

3. Read the patient’s insurance card carefully and send the claim to the correct address. When staff members do not search for the most current company address, the claim may not reach its destination and must be sent again. While waiting for the claim to be paid, the patient may lose confidence in the practice and decide to change doctors as a result of this mistake. Communications with the insurance company and/or practice may also cost the patient a great deal of personal time.

4. Double-check that you spelled the patient’s name correctly and that it matches the name that appears on the insurance card. In addition, check that you know who the insured party is, as it may not be the patient. For example, staff members assume that the 17-year-old student who is seen in your practice is the insured, when in fact, it’s the patient’s father. As a result, the claim may be denied and the balance will be transferred to the patient. Now, the patient will get a bill for services he or she does not actually owe because he or she does have adequate coverage but the claim was filed incorrectly.

5. Make sure that a referral or preauthorization is obtained for all services that require them. For example, if a staff member schedules a flexible sigmoidoscopy before the patient comes into the practice, but doesn’t follow up to see whether the service is preauthorized with the insurance company, the procedure may have to be rescheduled, greatly inconveniencing the patient.


Shannon Sousa is the editor of The Doctor's Office. She may be reached at ssousa@hcpro.com. This story was adapted from one that first appeared in the March edition of The Doctor’s Office, a publication by HealthLeaders Media.