CLINICAL VS. ADMINISTRATIVE

By: Melissa Tedder

The healthcare field has changed dramatically over the past several decades. The traditional $250 deductible-80/20 healthcare plans are few and far between these days. Managed care has rolled in and branded the words “co-pay”, “referral”, “prior authorization”, “formulary” and “non-covered service” across our foreheads. This has not only changed the financial aspects of our medical practice, it has also changed the resources available to treat our patients, the medications available to prescribe for them, and the manner in which treatment and prescribing should be provided.

This significant change in healthcare has changed the overall function of the medical office. The typical front office staff which in the past may have been titled “data entry clerk” has now evolved into an ingenious “insurance specialist” having to decode every paragraph of each insurance plan’s contract requirements. Posting daily charges has become a minute task compared to unscrambling the red tape of obtaining daily referrals and authorizations end explaining to patients why every plan within an insurance company isn’t the same and why today’s services may not be covered.

Remember the day when your medical assistant was actually your medical assistant? Today, the typical podiatric medical assistant has turned into a walking book of managed care knowledge. Since when does a patient’s insurance coverage determine the appropriate surgical facility? appropriate antibiotic? appropriate NSAID? Or what DME is medically necessary?

From my own experience, I am quite familiar with the evolution of today’s podiatric medical assistant. When I began in this field 14 years ago, my daily tasks were obtaining vitals, performing x-rays, preparing surgical trays, scheduling surgery and other typical medical assistant clinical duties, regardless of the patient’s insurance coverage. During the last decade, my role has changed significantly. The wide variety of managed care options available to patients these days has changed my position to that of “office analyzer” Each prescription written by the physician must be reviewed to determine if it is on the patient’s formulary and whether or not prior authorization is required. When the physician orders x-rays, I must determine if the patient’s insurance will cover this set of x-rays during the 90 day global post operative period. If surgery is recommended, will the patient be allowed to use the hospital net door or does he have to travel to the facility 30 miles across town. If durable medical equipment is recommended, will it be considered medically necessary or is there a DME ‘carve out’?

I find that most of my day now is consumed with countless hours of phone calls obtaining prior authorizations, prior approvals and pre-determinations rather than direct patient contact. I never would have imagined 14 years ago that upon obtaining a medical assisting job, I would have to be so knowledgeable in insurance and managed care. Without this knowledge, a poorly trained medical assistant could be a financial disaster to a podiatry practice.

I am sure that in the future, management within many podiatry practices will be considering these exact situations when hiring employees as behind every great doctor is an extraordinary staff.