Processes involving large volumes of complex billing transactions require effective mechanisms for problem assignment and tracking. Without such mechanisms, billing personnel cannot be held accountable for problem resolution, resulting in loss of revenue and increased compliance risk. While medical billing industry has developed specialized systems and processes for resolution of content problems, little attention has been paid to billing process problem resolution methodology. This article outlines a process and a technology for integrated billing process problem resolution methodology.

Billing Content and Billing Process Problems Require Different Tracking Methodologies

Medical billing exceptions can be categorized into content problems and process problems. Content problems have to do with claim content and patterns of processed claims, such as terminology, medical necessity, patient eligibility, denial followup, and regulatory billing compliance. Process problems have to do with claim formatting, system interfaces, entry of patient demographics, posting of charges and payments, printing and mailing or faxing of required information, provider interaction procedure, systems access, and HIPAA compliance.

While streamlining and transparency are important attributes for resolution of both kinds of problems, the required processes and systems are very different. Content problems tend to be specialized and therefore they lend themselves to a more structured, almost template-driven solution approach. Process problems, in contrast to content problems, tend to cover a wide variety of knowledge domains, precluding specialization.

The difference in solution methodology drives the difference in problem tracking. For content problem resolution methodology the reader is advised to consult companion articles on metrics, straight through billing, and billing transparency. The remainder of this article focuses on process problem tracking.

Billing Process Problem Tracking

A general-purpose tracking system allows opening problem ticket, its assignment to specific team member, its re-assignment or escalation, change of status depending on problem resolution stage, convenient reporting about sets of tickets in different states or assigned to different team members, and continuous notification of everybody involved about change of status. Therefore, such a tracking system (e.g., web-based TrackLogix) is constructed around three basic reports, notification mechanism, and a concept of ticket.

Problem Tracking Reports

The reports show

1. Tickets I owe to others
2. Tickets owed to me
3. Status - a summary table of the team participants with statistics of tickets in different states

Other reports may show and compare individual productivity and responsiveness.

Problem Notification

For transparency, the members of the team must be continuously aware of every problem resolution status. The simplest way to maintain such awareness is to send an email to every team member about every event of problem ticket status change. Other popular notification media include paging and SMS calls. More sophisticated methods involve selective notification based on nature of event or person assigned to problem resolution.

Problem Ticket

The ticket has the following data elements:

1. Subject - short description of problem
2. Owner - name of the employee responsible for issue resolution
3. Requestor - name of the manager that assigned the issue to the employee
4. Date - date the issue was identified and documented
5. Scheduled - date (time) this issue must be resolved
6. Body - a detailed issue description
7. Log - time-and owner-stamped history of all documentation, including
   1. Escalation. Issues may be escalated to upper management via TrackLogix by simply changing the Owner
   2. Priority change
   3. Status change
   4. Date change
   5. Owner change
   6. Specific action taken to resolve the issue
8. Priority - relative issue importance order among other issues on the same workbench.
9. Status
   1. Open for new issue
   2. Pending for resolved and waiting for approval
   3. Closed for resolved and approved

Vericle-like Straight Through Billing (STB) systems automate majority of billing transactions and focus manual followup on exceptions. A formal web-based process problem tracking system, such as TrackLogix, provides accountability, which is based on a precise account of all process problems and their resolution status. With such a tracking system, every process participant has visibility to other problems. An increased level of personal accountability promotes teamwork, increases client satisfaction, and assists in streamlining the process.

For more information about problem resolution transparency and its four attributes, including universality, continuity, ubiquity, and scalability, read our companion article about medical billing transparency.

Yuval Lirov

Yuval Lirov, PhD, author of "Mission Critical Systems Management" (Prentice Hall, 1997), inventor of multiple patents in artificial intelligence and computer security, and CEO of Vericle. Vericle delivers comprehensive practice workflow engine that integrates patient scheduling, electronic medical records (EMR), billing, transcription, and compliance management. It improves billing performance and reduces audit risk. Yuval invites you to post questions about and share your knowledge of medical billing and compliance at BillingWiki.