May 31, 2018 | Cathy Thomas Hess, BSN, RN, CWCN

3 Minute Read

Compliant Workflow Design: Engage, Define, Review, and Refine

Workflow design is a key step in your department’s clinical and operational efficiencies. Workflows enhance healthcare quality and safety, patient throughput, and care coordination. These steps occur from the moment the patient contacts the department through patient discharge. Workflows need to be defined, reviewed and refined as roles in the department change, medical record requirements change, regulatory requirements become mandatory, and denials are discovered. Although the list provided in this column is not exhaustive, it highlights questions to consider for process improvement.

Patient Registration Workflow

Revenue cycle processes are governed by policies that specify which payers cover specific services. Further, most payers have implemented medical necessity guidelines for wound care
services. Questions to consider for workflow design include:

  • What is the primary reason for the visit? Do comorbidities exist? Have you reviewed the physician order for complete diagnosis information?
  •  What are the patient demographics and insurance information?
  • What is the payer type? Is the wound care department contracted? Will the service be paid at a nonpar rate? Does the payer authorize wound care in the plan? Is your department an
    authorized payer center? Will the patient be sanctioned for using the center?
  •  Has coverage been verified prior to the patient visit? Determine coverage for the diagnoses on the physician order. Implement the Medicare Advance Beneficiary Notice if medical
    necessity or coverage fails. Determine whether the payer has coverage limitations and if utilization parameters will be a concern. Obtain precertification/preauthorization numbers.
  • What is your front-end collections process? Prepare the patient for copay, coinsurance, or deductible based on the findings prior to the visit.

Staff and Provider Workflows Mapping to Visit Types

Documentation components comprising the medical record support medical necessity and continuity of care. Remember, the goal for your documentation details is to provide the highest possible degree of clinical specificity. Consider:

  • What types of visits are seen in your department and how are they mapped to the schedule?
  • How are you constructing your documentation workflows to support the visit? How are you verifying the documentation requirements necessary to complete the visit (ie, hospital
    policies, National or Local Coverage Determination policies)?
  • What are the signature requirements for the documentation? How are staff and providers trained on documentation requirements?
  • How are you reconciling the documentation to ensure the visit is complete for coding, billing, and medical records review?

To read the full article in “Advances in Skin & Wound Care” by Cathy Thomas Hess, click here.

To read previous articles in “Advances in Skin & Wound Care” by Cathy Thomas Hess, click here.

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Cathy is Chief Clinical Officer for WoundExpert® and Vice President at Net Health, and in addition to being the MIPS Clinical Consultant for WoundExpert. She gained over 30 years of expertise in various acute care, long-term care, sub-acute care facilities, home-health agencies, and outpatient wound care department settings. Cathy is the author of Clinical Guide to Skin and Wound Care (also translated into Italian and Portuguese) – Eighth Edition published in September of 2018.

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