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Culture of Excellence

This assignment will review the information workflow process for insurance claims, specifically for durable medical equipment, home health care, or other authorizations requiring an external vendor. As a case management nurse, I have had various encounters with patients frustrated about pending claims and lack of communication from the insurance plan, providers, and/or vendors. The usual process for such claims is shown in the current workflow diagram, claims are triggered from provider visits where a need is identified, and the provider then creates supporting provider note(s). The referral order is then sent to a medical assistant or referral coordinator in the provider office, this person gathers the necessary information and submits an authorization request in the insurance online provider portal. The referral and information are then assigned to a utilization nurse who reviews the order and documents, approves the order, and submits it to the appropriate vendor. Once received the vendor reviews the documents and contacts the patient for delivery.

There are some existing problems with this process, it is noted that once the utilization nurse approves authorizations they do not ensure it was processed through the vendor. They do follow up and ensure the vendor received documents, but it is never verified that the patient was contacted and services rendered. It is not unheard of that authorization can fall through the cracks and the patient does not receive what is ordered……..Continue