A strong health care system doesn’t just rely on the doctors to maintain its success; it relies on skills beyond practicing medicine. Inside the Department, hundreds of positions, no matter how big or small, connect to taking care of the hospital’s patients.
Taking care of patients doesn’t just involve prescribing medicine or being a licensed surgeon. Caring for patients can involve ensuring insurance coverage for medically necessary procedures.
The Duke Patient Revenue Management Organization (PRMO), formed in 2001, ensures Duke Health’s healthcare system stands strong by incorporating different jobs that connect together like a spider web.
The PRMO has more than 1500 staff members who handle PRMO’s centralized revenue cycle function for all of Duke Health. The staff members who are specialized to manage revenue cycles are revenue managers. Under the PRMO is the Private Diagnostic Clinic (PDC). Both organizations have a team of revenue managers to handle their revenue cycles.
The PRMO/PDC trusts revenue managers to improve systems such as the electronic billing system, charge capture, and denials management through their intricate Current Procedural Terminology (CPT) coding skills, revenue cycle experience, extensive healthcare insurance knowledge, and data management. Duke Hospital abides by PRMO/PDC’s guidelines for efficient billing and revenue cycle operations.
Revenue managers’ role in PRMO/PDC’s system includes optimizing monetary reimbursement, providing coding education to healthcare providers, and maximizing overall profitability across the PDC. Financial Management Analyst Jennifer Garrett, Senior Revenue Manager Dianne Tadlock are the revenue managers for the Department of Medicine.
“We can pretty much make or break the revenue cycle,” said Tadlock. “The Department, the physicians, all depends on the receipts from [our] work to pay for their expenses.”
Tadlock and Garrett’s duties are so important; it’s crucial to collaborate with the Department’s prominent figureheads to complete their work.
The PDC’s doctors is given an orientation by Tadlock and Garrett on collecting documentation, billing, and collection procedures to ensure they understand their role in the revenue cycle process.
Although revenue mangers’ main focus is reimbursement for the Department, assisting patients with medical bills is also their job.
Almost every day, Tadlock and Garrett are tasked with helping patients work through appealing denied insurance claims. Sometimes, Tadlock and Garrett must contact patients’ physicians to write letters of medical necessity clarifying why a medical procedure was necessary with attached research.
“Because of the complications of healthcare these days, we frequently get asked to help unravel or make patients understand their bills, especially if there was a denial or if something wasn’t paid,” said Tadlock. “The PRMO reaches out to revenue managers because we’re specialized in this area to help patients with their bills.”
Garrett remembers a time when they spoke to a patient who was going through troubled times with an unusually high medical bill.
After this patient had a particular medical procedure done, the patient’s insurer denied the service inappropriately, which left the patient with bill collection letters in her mailbox.
The patient didn’t understand why they were receiving collection letters. After investigating the denial further, Garrett resolved the denial and stopped the collection letters. This left an unforgettable impact on the patient.
“[In 2015], this patient was a victim of the South Carolina floods,” said Garrett. “The patient told us that they lost everything. The patient said, ‘Although the bill wasn’t as devastating compared to everything else that happened, it made a difference because I didn’t have to worry about that anymore.’ Outcomes like that make you feel good when you were able to help, especially after that someone has been through such a hard time.”
Managing revenue cycles and other finances is a complex job on its own. As Tadlock and Garrett walk into work, they always shift focus on what is the highest priority for the day while serving patients, physicians and others who need their guidance.
For instance, when Tadlock and Garrett are helping patients with insurance, they go through four or more steps to answer the following questions: What is your monthly premium? What is your co-pay? What will be paid out-of-pocket? What is considered medically necessary? Where can the patient even go see a doctor at?
There are more insurance matters the managers check. However, several of those matters are difficult for patients to handle alone without proper knowledge of health insurance.
“Everyone has trouble understanding their insurance bills,” said Tadlock. “All those questions have to be answered. I try to help at least my mom through all those steps to make sure she gets the right insurance company, which depends on what her needs are. But we just really feel a lot of empathy for patients out there that are really trying to figure this all out.”
For Garrett and Tadlock, managing revenue cycle operations never leave them with a mundane day despite the everyday challenges attached with the job.
The surface of their desks is always fluctuating with documents from stakeholders, patients, and healthcare providers who need their expertise quickly and efficiently. Garrett said, “if you like a job where you’re going to have a clean desk or feel caught up when you go home, this is not the job for you.”
However, cluttered desks and the hundreds of emails needing a response doesn’t stop the two managers from pushing forward with the tasks and deadlines they’re trusted with every day.
“I’ve always had a passion for the revenue cycle,” said Tadlock. “As healthcare has progressed from the HIPPA service, to PCP, and then to Affordable Care Act, it’s been easier on me because we understand what happened before and why it’s happening now.”
This story was written by Tia Mitchell, communications intern for the Department of Medicine.