For example: Horizon OB/GYN

3 Physician Groups
12 Locations
27 Physicians

1 Central Billing Office ( CBO )

The Central Billing Office handles all the customer calls, billing to insurance companies, secondary billing to spouse/significant other insurance companies, and posting of payments to an application program.

The application program is commonly referred to as Medical Manager. In reality there are 4 major application programs that are prevalent in the market place. Horizon and Ent of Ga happen to utilize Medical Manger.

Every Physician in the three groups at Horizon provides care to hundreds of patients each week. The patients insurance company is billed for the visit by the appropriate reason code (CPT Code). The Insurance Company or Payor (i.e. BCBS, Aetna, United Healthcare has a negotiated contract with the group at Horizon for each CPT code and reimburses the physicians for the services rendered.

The Payer will batch the payments together by the patient name, service date, physician and other related information on their reimbursement to the physician group. This is referred to the explanation of benefits (EOB). With each EOB there is a check attached.
Typically, the batches are sent to a lock box at a bank for the deposit to be made. The purpose of the app program medical manager is to separate and post to the correct physician’s account the monies reimbursed. (There are many others and this is simplistic) At the end of the day the staff at the CBO must balance the batch against the postings.

It is very typical for most CBOs to file all the EOBs posted that day into one file folder with the date as the index. Each file has on average 300-400 EOBs in the manila folder. Most companies keep 1-2 yrs worth of EOBs available because there is usually a delay (2-3 months ) before an inquiry is made for the EOB.

The Problem:

At any time if there is a reason to doubt the posting accuracy, if there needs to be an adjustment or secondary billing, if a customer calls about the EOB they received, it is necessary to pull the file and find the original EOB to review the information.

The amount posted is viewable by the staff individual by looking into medical manager, but the reliability of the data or the inquiry usually requires the original EOB. Therefore, each person who has a request must get up from the desk, pull the file from the posted date, rifle through the file and try to find the EOB from a stack of others. This happens
Five to Ten times a day. Every day, Every Week, Every Month.

The collections department typically will pull double that amount. The time it takes to find the EOB’s manually based on labor savings alone; easily cost justifies a system 20 or system 50.

The Solution:

Setting up the docstar to capture the data by posted date and check number requires manual data entry. It is the easiest and quickest way to always get back to the batch 100% of the time.

At Horizon, we set up templates for 80% of the largest payors to zone ocr each eob and capture the employee name & ssn, service date, and physician name. In addition to the data captured electronically the posted date and check number are added manually.
This provides them with 6 references to the eob. It has been working very well to date.

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