Straight Through Billing Methodology for Medical Practice 

Medical billing complexity and massive volumes of daily claims render manual claims processes incapable of protecting both the provider and the payer from underpayments, overpayments, and billing compliance violations. Straight Through Billing addresses complexity and volume processing problems by automating the majority of the claim flow and focusing the billing follow-up specialists to exceptions only. A Straight Through Billing process flags problems, routes them for follow up, and enables online correction and resubmission. Straight Through Billing methodology implements billing service transparency and focuses management on strategic process improvement opportunities.

Straight Through Billing (STB) integrates billing process within the practice management workflow, automates vast majority of transactions, focuses manual labor on exceptions, and establishes a process for continuous improvement.

First, integrated practice management and billing workflow connects patient scheduling, medical record management, and billing into a single flow. Every participant of the practice management workflow receives a unified and coherent picture of practice workload, patient and provider location, resource availability, and cash flow.

Next, transaction automation streamlines and expedites billing process by automating claim validation, payer message reconciliation, and billing workflow management:

• Automated claim validation eliminates errors downstream and reduces processing time because it flags errors before submitting the claim to payer.
• Automated claim-message reconciliation eliminates costly search for the original claim and standardizes message communication, further eliminating the need to decipher the (often cryptic) payer's message.
• Billing workflow management drives the followup discipline required for resolution of claim denial and underpayment incidents and establishes high degree of process transparency for all billing process participants, resulting in full and timely payments.

Third, focusing manual labor to exceptions requires timely exception identification, routing to followup personnel, online error correction, and rigorous followup tracking. Again, process transparency, as implemented in vericle-like systems, enables tracking exception followup.

Finally, a process for continuous improvement requires continuous observability of every process attribute and a modification methodology for both automated claim processing and manual exception followup tracking.

STB implements billing transparency by design because billing transparency is an integral attribute of every component of STB process.

Straight Through Billing Architecture

Straight Through Billing systems architecture mirrors the architecture of general Straight Through Processing (STP) systems developed for the financial services industry. Such systems require effective workflow management, knowledge base validation system, connectivity to all process participants, including on-line data reconciliation, and tracking of problem resolution. Therefore, a typical vericle-like STB system has a three-tier architecture:

• Back-end processing engine designed for high-volume transaction processing environment
• Middle-tier uses Java Servlet technology
• Front-end is an HTML-JavaScript zero-footprint client

An STB system (e.g., Vericle) following the methodology outlined above implements rich functionality, which allows automated

• Computer aided preferential patient scheduling
• Integrated electronic medical records
• On-line computer aided coding
• Real-time claim validation and patient eligibility testing
• Electronic claim submission
• Payment posting, reconciliation, and verification of meeting contractual obligations
• Monitoring of audit risk and billing compliance
• Tracking of denial appeal process

Quantitative STB Management

STB methodology allows for quantitative management as the likelihood of failure of the entire process can be estimated as the product of such items for each individual workflow steps. A vericle-like STB system tracks the percent of clean claims (claims paid without any manual intervention in full and within the allocated timeframe) and focuses the management on those process aspects that yield the greatest potential improvement. Thus STB methodology focuses on exceptions both at tactical and strategic management levels.