Healthcare is a particularly tricky area because of the heavy industry regulation, the potential life-and-death impacts of workflow failures, and the high-dollar revenue impacts of incorrect or absent critical documentation required for payment of big-ticket hospital stays. Let us focus on one particular area of the patient’s experience at a hospital – scheduling an appointment for a visit or a surgical procedure.
Our sample scenario starts with a doctor calling to refer a patient for a certain type of procedure. Right here, you have something quite unique to healthcare, since the instigator of the transaction that is not the actual consumer of the transaction (i.e., the doctor is initiating the transaction on behalf of his/her patient). The agent at the hospital needs to capture an array of demographic information on the patient (name, date of birth, address, family members, etc.) and then has to be able to get insurance information for the patient, if available, as the vast majority of hospital services are paid by third-party medical insurance (including Medicare or Medicaid). Before much else happens, the agent must see if there are other records for the patient at the hospital so that previous medical history can be brought over to better inform care decisions on the part of the patient’s likely care team. A misspelled name, a transposed number in a date of birth, and vital information for the healthcare of that patient will not come over to the record and there will be two separate entries at the hospital for one patient with key health information not flowing to the caregiver.
A failure to complete these tasks in the right order and with the highest level of accuracy can have adverse consequences on a patient’s health and the hospital’s ability to be reimbursed for what will likely be a very expensive service
Continuing down this path, we encounter another anomaly of the world of healthcare; that the purchaser of healthcare services (the insurance company) is not the same as the person who is receiving those services. If the patient wanted to go out and, say, buy a vacuum cleaner, he/she would go to the store, pull out cash or a credit card, and the transaction would be consummated, just like that. With insurance companies generally footing the bill for expensive medical services, these companies often have very specific rules about what services are covered and under what circumstances these services will be compensated. Before a hospital goes too far down the road, they need to verify that the patient has the insurance that they purport to have. This can generally be done through a website, but it is critical to have some form of data flow that allows for deductibles, co-pays, etc., to flow back into the patient record at the hospital. Another significant twist is that different insurance companies may have different policies regarding “pre-authorization” or, in other words, submitting medical information to a review panel at the insurance company to allow them to determine if the patient’s condition warrants the expensive procedure or hospital stay. There are different requirements from company to company and, if the pre-authorization steps are not followed to the letter, the company will decline to pay for the service. It is on the hospital’s staff, typically, to submit these forms in concert with the primary care physician and other members of the patient’s care team. Insurance companies are not always timely in providing a yes/no answer or sometimes get back to the hospital asking for additional information. All these different patients have to be tracked to ensure that none of these requirements fall through the cracks.
Also, patients often have multiple insurances; one being “primary” and one being “secondary” to cover the outstanding balance after the primary insurance pays. Workflows need to be in place to bill the right insurance companies in the right order and to have at the ready whatever documentation the “secondary” insurance company needs to see what the primary insurance paid so that it can issue payment for the correct balance on the account.
Many of these processes can be performed electronically through web portals or through (somewhat) standard transactions that allow for a query and response to capture the necessary information. Not all companies utilize electronic transactions, which means that the hospital has to have provisions for checking this information manually. Sometimes insurance companies do use electronic transactions, but there are slight (or not-so-slight) differences in how the company needs to have the electronic transaction formatted. A failure to complete these tasks in the right order and with the highest level of accuracy can have adverse consequences on a patient’s health and the hospital’s ability to be reimbursed for what will likely be a very expensive service.
So, we haven’t even brought the patient into the hospital, and we are seeing the criticality of having the most optimized workflow that we can possibly have. Workflow in healthcare touches so many areas and is so complex because of the myriad of twists and turns involved in a healthcare process. It makes healthcare an unceasing challenge but one that the participants can gain a great sense of gratification from due to the positive impact that seemingly little things have on the well-being of our patients.
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