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Thread: Billing Workflow Model - by Payer or by Location

  1. #1

    Default Billing Workflow Model - by Payer or by Location

    AAPC: Back to School
    Hi! I am just looking for a general poll (as well as failure or success stories) as to how insurance denials, appeals, correspondence, etc are worked in a multispecialty clinic setting. I am working on revamping our current work model, but am trying to get a general idea of what other coders/billers are doing and how well it's working

    From what I can see there are three options, if you decide to go with a centralized billing staff: Work by Payer (Medicare, BCBS, Medicaid, Etc), Work by Location (or specialty - work all payer mix for each location) or a Mixed Model (work Govt Payers by Payer, work all others by Specialty, varied mixes).

    I'm looking forward to hearing how you have seen these process work and what types of successes (or failures) you have had/seen based on the setup of the workflow.

    Thank you!

  2. #2
    Join Date
    Apr 2007
    Dover Seacoast New Hampshire


    for efficiency, arrange your centralized billing staff by payer. This way they learn the payer rules inside and out. We've done it both ways, and this way is more effective. You certainly can cross-train (I'd encourage it), but allowing your billers to develop an expertise in regards to payer-specific rules, guidelines, denial reasons, etc. is valuable.

    Our coders (also centralized, by the way) are arranged by specialty, and not by payer. This way they develop coding expertise in one (or more) medical specialties. I expect our coders to code first by the coding guidelines, and then by payer guidelines when necessary.
    Pam Brooks, MHA, CPC, PCS, COC
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

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