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AMDO ST000001 Total Hip Replacement

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Mr. Adam Everyman is a 64-year-old male with severe pain in his right hip. He goes to his primary care provider, Dr. Patricia Primary, for an office visit.

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Mr. Everyman has previously enrolled in Health Insurance Coverage The receptionist enters all the pertinent information (PA, FM PM) from Mr. Everyman’s health card into her office system, verifies eligibility, and generates a charge - FM for the office visit to be invoiced at the end of the day to Mr. Everyman’s insurance carrier. During the office visit with Dr. Primary, Mr. Everyman is diagnosed with inflammation of the hip and receives a prescription for Naprosyn 500 mg. The prescription is for 30 tables to be dispensed, with directions to read “to be taken 3 times daily with food”.

At the end of the day, the receptionist transmits the information of all patients seen that day for the insurance carrier, including Mr. Everyman’s office visit, to the insurance carrier’s third party administrator. The receptionist receives a response from the third party administrator that they have received the Invoice and will inform the receptionist of the results when the Invoice is adjudicated. Four days later the receptionist receives the results of the adjudicated invoice results from the insurance carrier that they will pay $30.00 for Mr. Everyman’s office visit.

The above includes the following transactions: (move to separate page)

  • 1. Delayed billing for an office visit (batching)
  • 2. Delayed adjudication results

Mr. Everyman presents the prescription to Ms. Nelson, the pharmacist at the Local Pharmacy. Mr. Everyman is a regular patient at Local Pharmacy and his demographic and third party drug plan information is all on file in the Local Pharmacy prescription computer system.

Ms. Nelson enters the pertinent information from the new prescription in the Local Pharmacy system, then transmits the information as a real time claim to Mr. Everyman’s third party drug plan adjudicator. The data is processed through the computer system at the third party adjudicator. It is determined that Mr. Everyman is eligible to receive benefits, that this drug is a benefit under Mr. Everyman’s plan and that the quantity of the prescription falls within the drug plan guidelines. The third party adjudicator sends a message to the prescription system at Local Pharmacy, stating that they intend to pay for the claim for Mr. Everyman as submitted, less the applicable co-pay amount - FM of $5.00 – FM.

The above includes the following transactions: (move to separate page)

  • 1. Real time submission of a pharmacy dispense
  • 2. Real time adjudication of a pharmacy dispense

Mr. Adam Everyman was not relieved by the anti-inflammatory medication prescribed by Dr. Primary. Dr. Primary decided to refer -PC Mr. Everyman to an orthopedic surgeon, Dr. Sara Specialize, for evaluation. Dr. Primary’s receptionist schedules an appointment for Mr. Adam Everyman with Dr. Sara Specialize.

Dr. Specialize determines that Mr. Everyman is a good candidate for a total hip replacement due to a diagnosis of Vascular Necrosis of the Rt. Hip. Dr. Specialize has her receptionist send an authorization – FM request to Mr. Everyman’s insurance company. Mr. Everyman’s insurance carrier returns an approval for the surgery as requested by Dr. Specialize.

Dr. Specialize sends an order to the Good Health Hospital for admission to the GHH Inpatient Unit with a diagnosis of Vascular Necrosis of the Rt. Hip – PA, FM, PC. Additionally Dr. Specialize schedules a Total Right Hip Replacement (Scheduling Orders) with the operating room clerk who schedules the procedure directly into the ORIS. As a result of the admission order - FM, there is an order for pre surgical blood tests and urinalysis within 1 week before the surgery.

On the advice of Dr Specialize, Mr. Everyman schedules two blood donations in the event that he needs a blood transfusion following the surgery. The first donation is scheduled with the Good Health Hospital blood donation center 42 days before the surgery. The last is scheduled 8 days before surgery.

Mr. Everyman's insurance carrier requires that he also schedule a GHH Outpatient Clinic visit – PA, FM a few days before the surgery for an interview by the nursing staff concerning past medical history and current medications.

On the scheduled day of the pre-operative testing, Mr. Everyman presents (PA, FM, PM) at the GHH Outpatient Clinic, at which time he is registered for the clinic services. Mr. Everyman goes to the GHH lab for the required pre surgical blood tests, urinalysis and a chest x-ray.

On the appointed day, Mr. Everyman returns to the Good Health Hospital Admissions Department for admission for his surgery - PA.

The above includes the following transactions: (these are separate pages)

  • 1. Referral to Specialist
  • 2. Authorization for a surgical procedure
  • 3. Order (Request) for an Inpatient Visit
  • 4. Schedule of an inpatient visit
  • 5. Schedule of a surgical procedure
  • 6. Set up patient billing account
  • 7. Patient Registration and schedule appointments for:
    • Blood Bank
    • Pre op Everyman protocol for Clinic
  • 8. Admission to the Good Health Hospital