Best Practice Guidelines: Healthcare Practice Management
2. Introduction to Critical Business Processes
2.1. Introducing roles and responsibilities in the practice
To run a successful practice a healthcare practitioner must be concerned with all operations of the business and not just the medical aspects of the practice. As the practice grows, practitioners often become unable to perform the routine duties which once gave them control over their business. This lack of control can place the entire practice in jeopardy. Appointing competent personnel will assist the practitioner to ensure that all duties are performed and that the practice is thus run effectively and accurately.
Consider the following:
- Make sure that all employees know what their roles are in the practice and what is expected of each role by documenting the roles. A lack of proper role division and work definition can result in needed tasks not being completed.
- Role division gives the practice the ability to:
- divide work optimally between personnel;
- implement a separation of duties;
- implement access control;
- avoid labour disputes due to personnel not knowing what their responsibilities are.
- This best practice guidelines book is designed to assist the practice to implement proper procedures per role so that all critical business processes are completed and can be audited with the internal controls as described in the GoodX Healthcare Management Internal Controls book.
Roles in the practice
Appointments: Ensure that all his/her day's planning is on the electronic diary so that reception can manage the expectations of patients.
Communication: Ensure that all tasks received are completed, eg finalise scripting and review pathology reports and communicate results to Patients. Complete tasks and allocate tasks to the Practice Manager. Add tasks for the Stock Controller to order necessary stock items.
Diary Administration: Check the waiting room and manage the time per appointment with each patient. Inform the practice manager if some appointments must be postponed.
Clinical Information: The practitioner is the only person who is legally allowed to complete and access clinical/medical information about the patient. Clinical Information will be completed by the medical practitioner to keep a record of the patient’s health information, treatments, and/or medications that are used or will be used. The practitioner is legally bound to keep patient health records for a period of no less than 6 years.
Billing: Do billing and switching whilst treating the patient, or provide clear, readable and correct descriptions or ICD10 codes to the Billing Expert to avoid rejections. Timely communication and billing will ensure that patients don’t leave the practice after switch rejections due to for example insufficient funds. Keep record of procedures and all medicine and materials.
Appointments: Ensure that all information is on the diary so that anyone can manage the day to day bookings regardless of the availability of specific personnel.
Debtors & Patients: Ensure that all information is checked by Reception. Double check that all patients have electronic files. Ensure there are knowledgeable personnel available at reception to open files on a daily basis.
Communication: Ensure that all communication to and from Patients as well as all internal communication was successfully responded to. Complete all tasks and ensure all tasks of other personnel are done.
Diary Administration: Ensure that competent personnel are available to complete the day’s workload. Manage the waiting room and the time patients wait for consultations. Check the diary to see if all documents have been uploaded onto the software if all necessary processes were completed, that all theatre lists were sent to hospitals and that all correct information was added for the next day.
Billing: Design and check the process to get files and/or billing notes from the Practitioner to the Billing Expert and check that all billing is daily up to date.
Billing Corrections: Makes sure that corrections are done by authorised personnel by utilising the correct functions in the software. Checks all corrections on a daily and weekly basis to ensure that no unauthorised or unnecessary corrections were done. Ensures that only authorised personnel have access to do corrections.
Claim Administration: Check that all claims were sent before end of business day. Ensure all rejections have been dealt with on a daily basis. Ensure there are no “To be sent”, “error” or “flagged for submission” claims. Ensure the Billing Expert and Credit Controller relationship is in place and maintain proper communication between them.
Receipting: Check the cash and card reconciliations every day. Make sure the correct personnel are responsible to bank the cash. Allocate the correct cash to the petty cash if the cash is used for day-to-day expenses. When a reconciliation is not complete or does not reconcile, the discrepancy must be investigated. Ensure that all ERAs were posted and are balancing with the bank account.
Receipt Corrections: Check the cash and card reconciliations daily. Check that the ERAs balance with the bank account. When a reconciliation is incomplete or does not reconcile, the discrepancy must be investigated. Incorrect receipts can be written back by the Practice Manager.
Debt Management: Ensure that notes on the Age Analysis are updated. Approve journals. Approve and check that all information is accurate on accounts to be handed over for debt collection. Ensure that the practice receives feedback on accounts handed over for debt collection.
Reports: Ensure all transactions are up to date before reports are generated and sent to management. Draw and check all reports and send with notes (if needed) to the responsible manager(s). Implement management decisions to optimise operations.
Appointments: Complete all bookings for prior telephonic appointments, walk-in patients and online bookings. Manage all changes in bookings.
Debtors & Patients: Open electronic files of Debtors and Patients, upload all required documents and ensure the correct demographic details of debtors and patients. Do validations and benefit checks prior to the consultation. Double check the demographic information. When dependants pass away or get their own medical aid, they must be marked inactive and moved to their own electronic file.
Communication: Make sure all communication is responded to and all tasks are completed. Send SMS reminders for patients to remember appointments. Send birthday wishes to Patients and ensure all documentation is uploaded and up to date.
Diary Administration: Move, extend and cancel appointments. Multi-Doctor View can be used to ensure the correct management of all available time slots. Ensure all demographic information is correct and up to date. Compile the theatre list and schedule patients on the theatre list and complete all pertinent information. When appointments are cancelled, ensure that the Waiting List is managed (Desktop App only).
Communication: Check all tasks on a daily basis. Ensure all communication from the Practitioner was received, understood and completed. Make sure how the practitioner will communicate the codes that should be billed, eg by email, tasks, clinical events or the episode manager.
Billing: The Billing Expert needs to have advanced knowledge of the speciality’s billing codes and rules to ensure accurate and optimal billing. Ensure all medical aid billing is switched / sent to the medical aids and make sure all corrections are done. All billing must be done on a daily basis to ensure correct figures and healthy cash flow. Private patient billing must preferably be done before the patient leaves the practice so that the need for debt collection is limited.
Billing Corrections: Will process all billing corrections, eg Credit Notes, Redo Transactions and edit Invoice (Desktop App) functions. Utilises the appropriate functions for the different types of billing errors.
Claim Administration: Validations and Imported data are important tools to prevent rejections. Ensure all claims are sent on a daily basis. Follow up on all rejected claims or line items on the claims, do corrections and resend claims to medical aids. (Complete the 4 R’s: Reverse, Redo, Resend, Resolve.) Ensure all claims are dealt with and that Approved-in-full claims are resolved to update the list which the Credit Controller uses to follow up on outstanding claims.
Receipting: Receive all Patient payments: card and cash. The Cashier must allocate the payments to the correct accounts and print receipts for the patients where required. All cash and card payments must be reconciled every day. Bank the cash that was received for a certain period. When cash is used for day-to-day expenses, the cash must be given to the Practice Manager and allocated to the Petty Cash cash book before it is used for day-to-day expenses.
Receipt Corrections: Receive all patient payments (card and cash). Link all payments to the corresponding invoices. When errors occur, corrections must be requested from the Practice Manager or Credit Controller (Receipt Written Back).
Communication: Use SMS, email and VOIP calls to communication with Patients with outstanding accounts. All communication between the credit controller and the medical aid/patient must be documented and recorded. Complete all tasks.
Billing: Check that all billing and corrections were done and all medical aid claims and corrections were submitted. Ensure that all outstanding invoices are sent as soon as possible to patients.
Claim Administration: Ensure all possible methods are used to correct claims and all claims are sent to medical aids. Ensure medical aids receive all claims so that payment can be received with the next payment run of the medical aids. Ensure correct claims are marked as resolved and that claims that have not yet been resolved are flagged for debt collection.
Receipting: Allocate EFT payments to the correct patient accounts. ERAs must be posted on a daily basis but only when the amount is visible on the practice’s bank statements. ERAs that have not yet been received into the bank account of the practice, should not be posted, otherwise, there is no reminder to follow up on payments with Medical Aids that have not paid.
Receipt Corrections: Does receipt corrections. (This task can be performed by the Practice Manager or the Credit Controller.)
Debt Management: Follow a pre-designed debt collection cycle by completing tasks in each stage. Make notes and create tasks on a daily basis and follow up on those tasks. Contact medical aids and private patients for outstanding accounts. Accounts of 60+ days or older are URGENT accounts and must be dealt with immediately. Collect as much outstanding accounts as soon as possible to ensure healthy cash flow in the practice. Hand over outstanding accounts for formal debt collection. Journals must be posted to the correct Ledger accounts. Send patient outstanding accounts by email or sms.
Communication: Minimum & Maximum stock levels report should be used on a daily bases to see if stock should be ordered from Suppliers. Send orders by email to suppliers with the correct item information. Check tasks to ensure all instructions from Practitioners are completed.
Diary Administration: The stock controller should have access to the appointments, to know how many patients are booked. Ensure that the practice has enough stock to be able to treat the number of patients that are booked for a certain period plus the number of patients that the practice has the capacity to still book for that certain period. The reason for the appointment can be an indicator of the certain items that will be needed. Go through all the chronic patients to ensure the stock will be ready for the patients to be collected.
Billing: Go through all the stock that was billed and check that it is correct and everything that was taken has been billed. Ensure all stock that was used on patients and is not going to be charged, that the items are marked as non-chargeable and have been indicated that the items were used on the patient or on the patient’s account or as a non-chargeable account. Check that the correct item, strength and pack size were used with the billing. Confirm that the cost of sales has been calculated and are correct. Ensure there are stock to be billed and all supplier invoices are up to date.
Billing Corrections: Check that the proper correction was used. Credit notes will have an effect on the stock levels but journals not. Ensure when stock has been returned or not used on the patient that a credit note was done.
Reports: Check the audit trail to ensure the correct stock were billed. In stock management, more reports will be used to ensure the correct details.
Billing: Ensure that billing was done correctly and balances with the Audit Trail. Ensure that VAT calculations are correct.
Billing Corrections: Will draw reports to check that corrections are annotated with the appropriate reasons and that only authorised personnel had access to do corrections.
Receipt Corrections: Draw the list with the reasons of all the receipt corrections (Receipt Written Back). Check if proper reasons were given and if authorised personnel did the corrections.
Debt Management: Investigate the Age Analysis report on a regular basis. Ensure that the Credit Controller follows up on outstanding accounts and accounts were handed over correctly. Ensure that correct journals were done, and documentation is correct.
Reports: Check all reports, ensure all reports balance with each other and the information on the reports is correct. Send reports to the Auditors for the financial reports to be compiled and audited before submitted to SARS.