Electronic Health Records

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Identifying key stakeholders, activities of claims processing

By Kyle Murphy, PhD

Reimbursement is changing in healthcare. Even before elements of the Affordable Care Act began to go into effect, a growing focus on value versus volume has led many healthcare organizations and providers to consider accountable and patient-centered care models in which they assume a greater share of risk.

A successful claims processing operation comprises skilled personnel and well-monitored processes.

The revenue cycle which claims processing is but a part will vary according to the makeup of a healthcare organization as well as the billing model being used by that health system, hospital, or physician practices.

Here is a breakdown of personnel and activities within a hybrid billing model that marries both a decentralized and centralized billing models:*

Frontend staff

• Capture insurance data
• Verify Insurance and eligibility
• Conduct prior authorizations and obtain referrals
• Collect co-pays and deductibles at time of service
• Clinical staff
• Obtain patient consents and waivers


• Capture charges accurately
• Conduct timely completion of clinical documentation (affects charge lag)

Backend staff

• Track and resolve billing edits
• Conduct timely submission of claims to payors
• Follow up on outstanding A/R balances
• Post denials and resolve
• Engage in accurate payment posting
• Provide education and feedback to front-end staff and providers


• Ensure communication and feedback across all stakeholders
• Monitor staff performance
• Review revenue cycle metrics and analyze trends on a regular basis

In order that the revenue cycle functions smoothly and that opportunities for improvement in reimbursement are addressed in a timely fashion, leaders from the various departments in a healthcare organization must communicate in a scheduled way with certain meetings occurring more frequently than others.

For instance, whereas the business office manager and financial counselors and members eligibility/authorization team might on a biweekly basis to review trends in patient access, the group administrator, business office manager and business office staff might meet on a monthly basis to discuss underpayment trends, cash balancing, and claims-related problems or concerns.

No matter the size of an organized, key stakeholders and activities in claims processing from the front to the back should be organized in a standardized way.

Editor’s note: This information comes from an EHRIntelligence.com presentation given by Benjamin C. Colton of ECG Management Consultants, Inc. (View on-demand webcast).





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