To fulfill this responsibility and to comply with the Health Insurance Portability and Accountability Act of 1996 and its related regulations, HPI, LLC has implemented policies and standard procedures to protect
Description
To fulfill this responsibility and to comply with the Health Insurance Portability and Accountability Act of 1996 and its related regulations (“HIPAA”), Health Prime International, LLC (HPI) has implemented policies and standard procedures to protect the confidentiality and security of identified patient health information (“PHI”) in all its activities that requires the use and disclosure of PHI.
Our goal when working on a patient’s account is to maintain an exceptional level of security and privacy for our customers and their data in addition to responding with accurate and complete information in a timely manner.
** Should you have a question or concern regarding HIPPA in the realm of your duties, please consult HIPPA Guidelines in Confluence and / or your manager **
QA GUIDELINES (CALLS)
Security Compliance (Yes/No)
Providing a user with any information that falls outside their scope of permissions is considered a security violation. Security procedures must be followed exactly as outlined to avoid penalization. Any violation will result in automatic write up.
Verified Patient
Verified the patient by asking the full name and DOB. If it is an insurance representative who is calling, additionally, please request to verify patient’s Subscriber/member ID (insurance identification number).
Information can be disclosed with:
-Patient (after validation).
• Insurance representative (after validation)
• Power of attorney/responsible party (after validation).
• Relay Calls/Interpreters: After confirming if we have any documentation on files stating patient does require this type of service. For documentation of the call please include doc# & interpreter ID; assist as if you were talking to the patient directly. If we don’t have documentation of patient requiring interpreter/relay services then transfer the call to the practice for validation.
• Insurance Main subscriber: If main subscriber information is on the system. See below how to check this information:
− Check on documents for copy of insurance card to check if it includes the caller’s name.
− Check eligibility report to see is policy holder information is available. −
Insured information is saved on the patient account as shown below.
After successfully confirming that the caller is the patient or insurance, you can now provide any information
requested, both billing and medical. Here are some of examples of what can be shared:
• Balance
• Encounters
• CPT codes (Procedure Codes) and ICD-10 codes (Diagnosis Codes)
• Insurance information (Member ID, Group Number, Insured info)
• Itemized statements (Ledgers), Payment record and Receipts
• Adding or updating insurance information (Anyone calling us other than the patient can request to add or update insurance information on files, we only need to verify account as if we were assisting the patient and just make sure we run eligibility to confirm policy is active & information is correct; if no commercial insurance eligibility can be run, we better request copy of insurance card to make sure we are adding insurance properly. Please note
there is no need to run eligibility for WC, just forward the information to CSC as we normally do.
• Provider or practice information (Office Address, phone number, Tax ID #, NPI#, etc.): Information can be provided to Anyone calling & requesting provider or practice information we have on files. If caller hasn’t been authenticated and they are only asking for this as a general information request, it’s ok to provide the information as well. Please Do Not Refer Caller to Practice
Secured PHI
Protected Health Information was properly secured or not discussed during the interaction or send without encryption.
Automatic Zero (Auto‐Zero)
Violations of any HPI security procedures, HIPAA policies, or anything that intentionally is a disservice to our customers will result in an automatic zero quality score and possible disciplinary actions.
Intentional disservice includes but is not limited to the following examples:
• Not notating the patient account.
• Hanging up on a caller.
• Becoming argumentative with a caller.
• Deleting or making unnecessary changes on a patient account without the proper authorization. (Unless instructed and documented by a supervisor with customer authorization)
• Using hold without even attempting to give a proper opening to the call as an attempt to make patient disconnect the call.
• Accessing a Cancelled Practice Account (This May be considered a Privacy Breach).
CALLER CURSING OR USING PROFANITY
In case you have a rude caller on the line using profane language, kindly provide 2 warnings before disconnecting the call, and at the third warning please just inform the caller you will proceed to disconnect the call. For instance, you can say the following: “Ma’am/ Sr/ Mr…. /Ms…. You are using profane language on this call, I’m trying to assist the best I can & keep it professional, so I need your help please. Kindly stop using profane language, if you keep doing
so, I will have to disconnect this call as per quality assurance purposes”. On the second attempt, you let them know: “This is my second warning to let you that I will disconnect the call if you keep using profane language, kindly assist”. On the third attempt use the following phrase:” I’m sorry, but I’m going to hang up on you now, due to the repeated bad language. Please call back when you are happy to discuss the matter calmly and we will be more than glad to assist” and hang up immediately
Service (40 points)
Greeting: (5 points)
1. Greeting and thanking the customer for contacting (Patient Relations or use other practice name if special practice is accessed, for instance: Care First Urgent care for CG Medical).
• Use, “Hello, thank you for contacting (Patient Financial Services/Care First Urgent Care, etc.)”
2. Introductions:
• Provide your name.
• Ask for their name (and use it when appropriate)
3. Ask for the medical practice name, the provider’s name, or who sent the bill:
• “Who is your statement from?" (Located on the top left corner of the statement) or “For which medical practice/provider are you calling for?”. Please note, no need to ask for practice name if we are working on a special account and if practice name is on the hard phone, for instance First care urgent care for CG Medical.
• "What is your account number?" (Located on the top right of the statement above "Please remit payment to...")
4. Verify the practice RCM status:
• Confirm if the practice has active services with us. This can be done by reviewing the company’s profile in HubSpot under “RCM Status.”
• If the practice is active or under a “cancellation in progress status”, we can continue with the call.
• If the practice is NOT active, politely inform the caller that we do not handle the billing services for this practice, and that they will have to reach out directly to them.
It will result in an auto‐zero if accessing a cancelled practice account, since this may cause a privacy breach; this will be considered falling outside of security compliance.
5. Asking for Caller Contact Phone Number:
• It is mandatory to obtain a valid call back number from the caller, in case the call gets disconnected. You can even verify if the number the patient is calling from is valid or asking for their best call back number.
Verification: (Yes/No)
1. Confirm if the caller is the patient:
Make sure to check if the caller is the patient by asking, “Are you the patient?”.
If the caller is not the patient:
• Verify if he/she shows as the guarantor/responsible party on file. Please make sure to check this in both the “responsible party/guarantor” section, and in those cases where there is more than one responsible party, also check the patient’s alerts. If the caller is indeed the responsible party and confirms the patient’s full name and date of birth, continue with the call, and feel free to disclose any information as if the caller was the patient.
• Verify if he/she shows as the insurance holder on file by checking if there is a copy of insurance card or if the caller is added as the main subscriber of the insurance policy.
• If an insurance representative is calling, besides patient’s full name and DOB, Insurance ID/Member ID needs to be provided by caller.
• If the caller does not show as the responsible party, and there is no way to confirm this with the information on file, then you can only provide the patient’s balance, take a payment and add/update insurance information on files. If the caller wants more information, politely communicate to the caller that we are unable to disclose any account information without having the patient on the line.
• If someone from the Dr’s office is calling to get some patient information, kindly ask them to confirm the practice KID. Nonetheless, if they don’t have that information available that’s fine; we still need to confirm if this person is authorized, and we can do this looking for caller’s name under practice settings and then from the dropdown choose the option that says: User Accounts. If the caller’s name is not there, apologize and please let them know you cannot proceed with the call unless they have the patient on the line, thus we can get the authorization, or the patient can give us a call later if not available.
If the caller is the patient:
• Verify security by asking the patient, “May I please have your full name and date of birth?”, If you have a hard time understanding the patient’s name, you can request to have their name spelled.
• If at any point the caller cannot verify or is unwilling to verify the information, kindly let them know as a first warning: "I apologize, but due to patient privacy we cannot discuss this account with you without verifying this information."
• If they still are unwilling, or cannot verify the information, kindly say: "I apologize, but I am not going to be able to help you at this time. Please feel free to give us a call back when you have the patient on the line. Thank you and have a nice day." Disconnect the call and make a note in the account.
If the caller is an attorney’s office:
• If the caller can verify the patient’s full name and date of birth (Insurance ID, if insurance representative is the one calling), we can provide the patient’s balance, take a payment or add/update insurance information. PHI can only be disclosed with the patient on the line (Three-Way call), for further information request an authorization form signed by the patient.
2. Score 0 on this line will result in an auto‐zero.
3. When to Request a Patient Signed HIPPA Form To be Sent to Us?
• Please note, for any PT relative or third-party person that may want to be authorized on files to discuss or receive patient billing information with us on the phone other than checking balance, making payments or adding/updating insurance, we can request patient verbal approval on the phone or offer to connect the call to the office so they can be added as authorized on files.
• For any attorney’s office representative that calls in requesting patient information such as: Itemized bill, billing records or any other patient demographic information on which we need to have patient approval before releasing information.
• If Request is for Medical Records (Refer to the office only if it’s not related to a denied claim; we can assist in case we have an insurance rep calling for a denied claim). If the request is for any other kind of documentation needed to process or pay for a patient claim, for instance: A Medical Record or a precertification approval, and if request comes from insurance rep, please find below further details on how to proceed.
• Please remember that in case we have a denied claim on which insurance is requesting Medical Records, a prior authorization or any other kind of important information needed to process the claim, we are not supposed to refer insurance representative to the office or request any HIPPA form to be sent to us since we are supposed to submit a ticket so our A/R department can follow up on it and make sure this is sent to payer correctly for claim to be paid. Please only gather all the details regarding dos and bill amount the call is about, and please also obtain fax# or mailing address where we are supposed to submit the documentation to and forward that to CSC.
Professional Communication: (5 points)
1. Customer acknowledgment and courtesies:
• When the customer provides information or asks a question, be sure to acknowledge it.
• Allow the customer to complete their thought/sentence(s) without interruptions. If you happen to interrupt them, apologize for doing so.
• If needed, place the caller on hold instead of using excessive dead air (it should be less than 30 secs max).
2. Verbiage used:
• Do not use slang, profanity, emojis or unprofessional acronyms (lol, jk, brb, etc.).
• Avoid industry acronyms (PM, DOS, DOI, etc.) unless the customer has already used them.
• Maintain basic Kareo terminology. Do not use technical jargon.
Hold Courtesy: (10 points)
1. Ask permission and show appreciation:
• Use, "May I place you on hold while I research?" or "May I place you on a brief hold?".
• Address the hold or delay when you return to the conversation. Use, "Thank you for your patience while holding".
2. Less than 3 minutes of hold time:
• A check‐in must happen within 3 minutes intervals.
• After the first check‐in, if additional hold time is needed (and you anticipate it will be another 5 minutes hold), you must ask the customer if they would like to continue holding or prefer a call/email back.
• If you unintentionally take the customer off hold, make sure to verbally check in with them; do not just quickly place them back on hold.
Empathy: (10 points)
1. Overall tone:
• Sound friendly and willing to help.
• Speak clearly. Do not mumble or talk to yourself; this confuses the customer.
• Do not display confusion, frustration, or pessimistic/negative behavior.
• Display empathy when a customer expresses their anger, frustration and/or disappointment.
• Acknowledge the issue of the patient.
2. Score 0 on this line will result in an auto‐zero.
Standard Closing: (10 points)
1. Offering further assistance:
• Use, "May I be of any further assistance" or "Is there anything else I may assist you with today?"
• Do not assume the caller has no further questions. Avoid using, "If you have no further questions" or "Feel free to call us back".
• Unless the caller has confirmed there are no further issues now (i.e., today, at this time), is a must to offer further assistance after each inquiry.
2. Offering survey:
• Please use a phrase offering survey to the caller, you may say something like this: " We value your feedback, at the end of this call there is a brief survey regarding my performance today, I would greatly appreciate your feedback, if you would like to take the survey, please stay on the line”.
3. Thanking the caller for contacting Patient Financial Services/ Care First Urgent Care or other special practice name call was received for, showing appreciation of their time, or appropriate closing:
• Use, "Thank you for contacting Patient Financial Services/ Care first urgent care, etc" or "Thank you for your
time"
Proficiency (45 points)
Active Listening: (10 points)
1. Pay attention to the caller.
2. Give the caller undivided attention. Do not make them repeat themselves.
3. In case name provided is not clear, apologize, and ask the customer to please spell it out.
Problem Identification: (15 points)
1. Asking relevant, probing and clarification questions:
• Allow the caller to fully explain their issue and listen for identifying keywords.
• Ask relevant questions to narrow the scope of an issue and find out what they wish to accomplish.
• Repeat important details back and use clarifying statements (parroting) to ensure you fully understand their issue.
2. Research:
• Use all your resources according to the issue of the patient.
• In case the issue needs to be addressed by the OPS consultant, contact them through Microsoft Teams, call or create a HubSpot ticket.
Provided Solution: (15 points)
1. Correct solution:
• All issues/inquiries were addressed correctly. "I don't know," or "I guess" are not acceptable answers to inquiries.
• The solution(s) and possible outcome(s) were provided so the customer clearly understands and can identify which option (if multiple) works best for them.
2. Score 0 on this line will result in an auto‐zero.
3. Not communicating with the customer in the excepted timeframe.
Setting Expectation: (5 points)
1. Set expectations:
• Accurate timeframes were given when applicable.
• Do not promise a resolution or feature will be available if we cannot guarantee it.
• When multiple solutions are provided, make sure to fully explain the possible outcomes.
Case Management (15 points)
Case Handling: (5 points)
1. The ticket/task has been created and assigned to the correct representative/Ops consultant.
2. The required fields on the case are populated with the correct information.
3. The ticket/task has been created following the according SOP.
4. The ticket/task was created for a valid reason or scenario. (Was not unnecessarily created)
5. The ticket number has been provided to the customer for further follow up.
NOTE: 0 score will be applied under this section if a ticket/ task is submitted unnecessarily, and agent will still be scored down under resolution section since no resolution is provided on the call, but no 0 score will apply under resolution section.
Documentation: (10 points)
1. There should be no question as to what transpired during the interaction.
2. The subject of the case must include the Patient ID.
3. The notes need to be clear and explained everything that was done during the call.
4. If there is something else to complete after the call, make sure to document it.
5. If you need to create a case, make sure the description and the comments are clear and explains what is needed
or what is the issue.
6. Score 0 on this line will result in an auto‐zero.