Any process without a quality check is not complete. And where the financial management is concerned, one cannot go wrong and it would have a boomerang effect if it is not checked at every stage of the process.
HIPAA: Kaiser strictly follows the guidelines and rules and regulations governed by the Health Insurance Portability and Accountability act.
Quality Process at the Coding Process: The coders in place are qualified in AAPC (American Academy of Professional Coders) and are updated with the latest in the coding field. A test is conducted every month to check the accuracy of coders since the whole billing process starts with coding. Any error at this level would involve financial discrepancy since every procedure is connected to a specific revenue and if wrongly coded would get noticed at the quality check or at the insurance company level or at the patient level leading to unnecessary time delay leading to delay in payment. A high degree of quality check is in place to train, update and ensure appropriate coding.
Quality Process at the Charge Entry Process: The Charge Entry team needs to be well versed in the billing software and to enter the correct Diagnosis code and CPT code and ensure the demographical details in terms of the insurance company are in order. Since the billing software is different for different Healthcare Providers/ Hospitals/ Billing Company, the associates are trained for their technical skills and charge entry operations. A monthly test is conducted to ensure their expertise in handling billing software and charge entry operation. Once the charge entry is completed, it goes to the Quality Team. The quality team check the claims for correctness and submit the claim by electronic claim submission. A double quality check in place. The first is at the associate level and second at quality team level.
Quality Process at the Payment Posting Process: The quality team checks the correctness of the accounts being closed after receiving complete payment from the insurance company.
Quality Process at the AR Follow up Process: This is the most important process which involves interaction with the clients and the insurance company to address the denials and ensure follow up to complete transaction with the insurance company. The specialization for this process involves technical knowhow of all the reasons for the denial and the procedures thereto. The AR Follow up team goes through rigorous quality training in terms the complete billing cycle since they need to know the complete process to check where the things have gone wrong and how to fix it. A fortnightly quality meeting takes place to brainstorm the different contingencies of denials and how to address them at the earliest and accurately. The quality team follows up with the AR follow up team and updates the Operational Manager weekly. The Operational Manager keeps the clients updated with the pending issues and the reasons for the same till such time the payment is made by the insurance company.
Monthly Quality Report: A monthly quality report is sent to the client updating them about the pending claims and the reasons there to and their help taken to expedite payment from the insurance company.