September 2019CIOAPPLICATIONS.COM9same 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. 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 serviceRich Temple
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