Dr. Jennifer Dulaney Medical Billing Protocols and Audit Notes

Billing for Personal Patients:
- For deliveries of Dr. Dulaney’s own patients, billing must be submitted regarding the care provided for either a vaginal delivery or a C-section.
Contractual Billing for Other Physicians:
- This category applies to deliveries performed for physicians at Cornerstone Clinic or for Dr. Zis Weisberg.
- The billing method is determined strictly by the patient's insurance type.
- Commercial/Private Insurance or Other Non-Medicaid Payers:
  - Claims are not submitted to the insurance company directly by Dr. Dulaney’s office.
  - The bill is submitted directly to Cornerstone Clinic or Zis Weisberg / Methodist Hospital Hill Country/ PSG.
  - This arrangement exists because of a contract where Dr. Dulaney provides care and the clinics provide a pre-negotiated fee to her; an “OSA”.
- Medicaid Patients:
  - If the patient has Medicaid, Dr. Dulaney must bill the Medicaid entity directly for the delivery.
- Ambiguity Regarding Ambetter:
  - It is currently unclear whether Ambetter insurance falls under the Medicaid category (direct billing) or the contractual category (billing the clinic).
  - Resolution of this status must be addressed with Will Wilkes, the office manager at Cornerstone Clinic.

Labor Management Fees:
- Personal Patients: If Dr. Dulaney manages labor for her own patients, there is no separate fee charged. The management of labor is considered part of the global fee for the delivery.
- Contracted Patients (Cornerstone or Dr. Weisberg):
  - Labor is treated as a separate entity from delivery.
  - A fee is charged to either Cornerstone Clinic or Dr. Zis Weisberg if she manages labor, regardless of whether she ultimately performs the delivery herself or not.
  - Medicaid Restriction: Dr. Dulaney cannot bill labor management separately for patients with Medicaid.
Hospital Discharges and Rounding:
- Contractual Care (Cornerstone or Dr. Weisberg):
  - Dr. Dulaney submits a fee to the clinics for discharging their patients from the OB department.
  - Billing for labor, delivery, and discharge is permissible to the clinics provided the patient does not have Medicaid.
- Medicaid Restrictions:
  - For Medicaid patients, Dr. Dulaney cannot bill for labor.
  - She cannot bill for postpartum discharge if she performed the delivery.
  - Exception: She may possibly bill Medicaid for a postpartum discharge if Cornerstone or Dr. Weisberg performed the delivery and they did not claim it as a global fee. This aspect requires clarification from Will Wilkes.
- Excluded Services:
  - Dr. Dulaney cannot bill for "simple rounding."
  - No billing is allowed for postpartum rounds.

GYN Consultations and Admissions:
- This applies to care involving gynecology consultations and admissions originating from the Emergency Room (ER) or the Medical Hospitalist service.
- These services are billed to the patient's insurance or payer based on the specific service provided.
Antepartum Admissions:
- This includes admissions not related to immediate labor and delivery (e.g., if a patient is admitted for stability or monitoring).
- This applies to Dr. Dulaney’s own patients, Cornerstone patients, or Dr. Weisberg’s patients.
- These must be billed to the insurance (Commercial or Medicaid) based on the specific service provided and the diagnosis.

eClinicalWorks (eClinicals) Procedures:
- A patient account must be created in eClinicalWorks for all claims submitted to insurance.
- Claims for the following must be sent through eClinicalWorks:
  - Deliveries (Medicaid/Personal).
  - ER Consultations.
  - General Admissions.
  - Antepartum Admissions.
  - Billable Discharges.
- Contractual Exception: If Dr. Dulaney is billing the other clinics (Cornerstone or Weisberg) based on the contract fee, the patient does not need a claim created in eCW.
Surgical Tracking:
- All scheduled GYN cases that Dr. Dulaney takes to the Operating Room (OR) at Methodist Hospital Hill Country must be tracked.
- Claims for these surgeries must be created and submitted through eClinicalWorks.

Timeline and Status of Billing:
- Verified Status: Billing is confirmed up to date through $04/01/2026$ .
- Uncertain Status: It is believed billing is current through $04/30/2026$ , but this is uncertain due to the abrupt departure of Jan in April.
- Incomplete Periods: No billing has been performed for the months of May, June, or July, with the following possible exceptions:
  - Deliveries performed by Dr. Dulaney for her own patients (Suzi may have created some claims for these).
  - Some GYN surgical claims for May might have been created.
Immediate Financial and Administrative Tasks:
- Claim Verification: Follow-up is required on all claims created from early April to the current date. Specifically:
  - Have they been submitted?
  - Have they been paid?
- Contract Reconciliation: Ensure that requests for payment based on the provider contracts have been submitted to Cornerstone and Dr. Ziss Weisberg.
- Account Payables: Reconciliation is needed to determine if any funds are owed to Cornerstone Clinic.
- Dr. Weisberg Reconciliation: Dr. Dulaney does not believe she owes Dr. Weisberg any fees, as he hasn't performed a delivery for her in a long timeframe, though this needs confirmation.

Will Wilkes: Office Manager at Cornerstone Clinic; primary contact for clearing billing ambiguities regarding Ambetter and Global Medicaid discharge rules.
Bruce is the final contact point for reconciling payment for the OSA; need to review records from Jan’s files.
Need to determine primary staff member for billing of the various actions performed by Dr. Dulaney. This will help streamline the billing process and ensure that all charges related to patient care are accurately recorded and billed accordingly. Work load should be divided among staff members to ease the burden rather than task a single person.