Medical Billing: When Things Go Wrong
A new provider has been added and your provider enrollment person tells you all the paper work is in, the provider can see and bill patients. Then you find out a mistake was made and thousands of dollars in charges cannot be billed. Or a new insurance rule has been added and no one caught it, and thousands of dollars go out the door incorrectly and must be reviewed and re-submitted. Or filing limits change and suddenly you have denials piling up. Or a carrier has denied claims that should have been paid. Or a person who is the key to MCR department has an accident and suddenly you are left looking for someone to fill very big shoes.
There are many things that can go wrong in a typical revenue cycle process. There are so many components to the process that sometimes things just get lost in the process. Or key people go out on leave or carriers change the rules.
So what's the first thing to do? The very first thing to do is to identify the problem and the scope of the problem. Investigate the problem and the ramifications of the problem. Put a dollar value on the problem.
The second thing is to be completely open about the problem. There is nothing worse in an organization that realizing there is an issue and then trying to hide it. Take your lumps and allow higher management to communicate the issue to appropriate persons. The sooner someone knows about the problem; the quicker they can manage the fallout. Even if the dollar amount is low, tell someone.
At the same time, stop whatever process is causing the problem and fix it. This may mean getting on the phone with a carrier and finding out from them how they would like to handle. In some cases, they may have a way of re-processing internally without re-submission. In other cases, re-submission may be necessary. Depending on the size and scope of the issue, you may want a team of people to focus on the fix and get corrected claims out the door. Talking to carriers in a way that asks for their help and not being adversarial usually results in positive results. Of course there are times when you need to put your armor on and get ready for battle. Be sure you have analyzed the issue accurately before calling. In the case of a key person out, they may begin to evaluate how to best fill that position in the short-term. You may need some temp help as you move people up and around to fill position.
Don't panic, get the facts, be as dispassionate as possible so that emotions do not cloud the issue or the fix. People make mistakes, life happens. You will have plenty of time to take corrective action if it is called for.
Most of all, learn from the issue, don't just plug holes. Make sure everyone learns and understands how important it is to keep on top of the process every day.