Patients or Payers – Which Come First at Your Practice?

January 26, 2016 by Antonio Arias, MBA, CHBME

Topics: Medical Billing, Revenue Cycle Management, Practice Management

A high-functioning medical establishment – like any other business – should ideally operate like a well-oiled machine. Your office policies should be clearly defined, your staff should be trained to follow them, and your employees should be motivated to execute their responsibilities in line with expectations.

And nowhere should those expectations be more clearly defined than when it comes to dealing with insurers. Ever-changing and illogical as they sometimes may be, payers have nothing but medical billing rules. Working with payers successfully requires your practice to adhere to rigid guidelines, so making sure your staff knows, understands, and follows those guidelines is vital to your bottom line.

Maintaining and enforcing office-wide policies about payers’ is undoubtedly a huge part of your HR program. But what happens when payer rules collide with patient care?

Consider, for example, an incident recently detailed by writer P.J. Cloud-Moulds on Physicians Practice. A patient covered by Blue Shield arrives for an appointment at physical therapy practice, but is turned away by the front desk person. Why? Because Blue Shield requires a prescription from a doctor prior to a physical therapy visit, and the patient didn’t have one.

“She read the insurance verification from the intake specialist that said, ‘Prescription required by Blue Shield,’ and assumed the patient couldn't be seen,” writes Cloud-Molds. “Technically, the front-office person was following insurance guidelines. But, why did she not stop, take a moment, and ask the question ‘Is there another way we can see this patient for her evaluation?’”

Therein lies an essential problem: While highly structured, follow-the-rules environment makes for the best kind of practice from a management perspective, it can make for the worst kind of practice from a patient’s perspective – especially when it engenders employees to act like ‘rules are rules’ and other options are off the table.

As Cloud-Moulds goes on to explain, there were plenty of other ways the front-desk staffer could have handled the dilemma: She could have called the patient’s doctor’s office to request a faxed prescription; seen the patient, then sent the evaluation to the physician's office for a countersignature; or offered to see the client for cash payment only.

But the front desk attendant did none of those… and it’s worth considering whether your clerical staff would have handled the situation the same way she did.

Management teams, across all industries, love to believe their employees will think on their feet and seek smart solutions when faced with problems related to patients or payers. But in a medical office where following policy – yours or an insurer’s – is prioritized over showing patients kindness, employees can be fearful of ‘getting in trouble’ if they circumvent defined guidelines.

Revisit your practice management policies, training procedures, and overall office expectations to make sure employees understand that patients come first. Sit down with your staff periodically to talk about practice-patient interactions and issues. Pose hypothetical scenarios to your front-line team to find out how they’d handle problematic situations. Encourage your medical billing and administrative staffers to always ask their superiors for advice before turning patients away (over an error message on the check-in screen or anything else).

Consider even incorporating content on a ‘patients first’ ethos into your office policies. That way, even the most disciplined rule-followers on your team will know that finding smart solutions to patient problems is its own office guideline.

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