Patient Registration: Capture and manage patient information, including personal details, insurance information, and medical history.
Patient Profiles: Maintain up-to-date patient profiles with contact information, medical records, and insurance details.
Appointment and Service Tracking
Appointment Scheduling: Track and manage patient appointments, including appointment dates, times, and types of services provided.
Service Documentation: Document the services provided during each visit, including procedures, diagnostics, and treatments.
Charge Capture
Service Codes: Support the entry and management of service codes (e.g., CPT, ICD-10) to accurately reflect medical services rendered.
Charge Entry: Allow for the entry of charges for services rendered, including modifiers and units of service.
Insurance Verification
Eligibility Checks: Verify patient insurance eligibility and coverage before services are rendered.
Authorization Management: Manage pre-authorizations and referrals required for specific treatments or procedures.
Claim Management
Claim Creation: Generate claims based on patient services and charges, including required coding and documentation.
Claim Submission: Submit claims electronically or via paper to insurance carriers and other payers.
Claim Tracking: Track the status of submitted claims, including pending, approved, denied, and rejected claims.
Billing and Payments
Patient Billing: Generate and send patient bills for services rendered, including itemized charges and payment instructions.
Payment Processing: Process payments from patients and insurance companies, including handling copayments, deductibles, and adjustments.
Payment Posting: Post payments and adjustments to patient accounts, and reconcile payments with claims.
Account Management
Patient Statements: Generate and manage patient statements, including balance due and payment history.
Outstanding Balances: Track and manage outstanding balances, including overdue accounts and collection efforts.
Reporting and Analytics
Financial Reports: Generate financial reports, including revenue reports, accounts receivable aging, and payment summaries.
Claims Reports: Provide reports on claims status, denials, and rejections to facilitate follow-up and appeals.
Performance Analytics: Analyze billing performance metrics, including claim approval rates and revenue cycles.
Compliance and Auditing
Regulatory Compliance: Ensure compliance with healthcare billing regulations and standards (e.g., HIPAA, CMS guidelines).
Audit Trails: Maintain audit trails of all billing activities, including changes, submissions, and payment transactions.
Integration
Electronic Health Records (EHR): Integrate with EHR systems to access patient data and streamline billing processes.
Practice Management Systems: Integrate with practice management systems for appointment scheduling and service documentation.
Payment Gateways: Integrate with payment gateways for online payment processing.
User Management
Role-Based Access: Implement role-based access control to manage user permissions for billing, claims, and reporting.
User Profiles: Manage user profiles and authentication settings, including password management and multi-factor authentication.
Non-Functional Requirements
Performance
Response Time: Ensure fast response times for billing operations, claim processing, and report generation (e.g., under 2 seconds for most operations).
Scalability: The system should handle increasing volumes of billing transactions and claims without performance degradation.
Reliability
Uptime: Ensure high system availability with minimal downtime (e.g., 99.9% uptime).
Error Handling: Implement robust error handling and recovery mechanisms to manage system failures and ensure data integrity.
Security
Data Protection: Protect sensitive patient and billing data through encryption and secure storage.
Authentication and Authorization: Use secure authentication methods and role-based access control to manage user access and permissions.
Compliance: Ensure compliance with data protection regulations and standards (e.g., HIPAA).
Usability
User Interface: Design an intuitive and user-friendly interface for managing billing tasks, claims, and patient information.
Accessibility: Ensure the system is accessible to users with disabilities, following accessibility standards (e.g., WCAG).
Maintainability
Code Quality: Write high-quality, well-documented code to facilitate system maintenance and updates.
Documentation: Provide comprehensive documentation for users, administrators, and developers, including user guides, technical manuals, and troubleshooting guides.
Availability
Backup and Recovery: Implement regular data backups and establish procedures for data recovery in case of system failures or data loss.
Failover: Ensure the system has failover capabilities to switch to backup systems or servers if necessary.
Portability
Cross-Platform Compatibility: Ensure the system is compatible with various devices and operating systems used by users, including desktops, tablets, and mobile devices.
Supportability
Technical Support: Provide mechanisms for obtaining technical support and resolving issues, including help desks, online resources, and customer service.
Error Reporting: Include functionality for reporting issues or bugs and tracking their resolution.
