California Public Health Billing Project

Denise Smith, PHN, MPA Director of Disease Control

Kern County Public Health Services Director, California Public Health Billing Project

TODAY

Services are free at the Health Department!

NYC

Planning Grants

Duane Kilgus; CDC Stakeholder Meeting, February 1, 2012

CA Insurance Landscape

52.1%

14.5%

6.1%

8.8%

18.5% Insurance Coverage

Private Insurance

Medi-Cal

Medicare

Other Coverage

No coverage

State Capacity Analysis

• 10% provide immunizations only

• 7% provide immunizations and one other service (i.e., family planning, TB clinic, STD services, HIV services, prenatal services)

• 25% provide immunizations and two other services

• 38% provide immunizations and three or more other services

• 8% provide primary care services including immunizations.

Clinical Services:

State Capacity Analysis

• 11% bill insurance, Medi-Cal, and Medicare

• 31% complete Medicare roster billing only (flu

vaccine)

• 18% bill Medi-Cal and complete Medicare

roster billing

• 7% bill Medi-Cal only.

• 20% complete no billing and provide services

for free or a nominal administration fee.

• 13% provide no clinic services at all.

Billing Services

Kern County Landscape

Potential revenue if

insurance had been

billed

2008/09: $210,640

2009/10: $228,931

77%

23%

2008-2009

VFC Eligible 317

57%

43%

2009 - 2010

VFC Eligible 317

Kern’s Process

Updated Fee Schedule

Initiated Private Insurance Contracts

Provider Credentialing

Enhanced Insurance verification

Improved Coding & Medical documentation

Developed better Clinic Flow and Staff

placement

Fee Schedules

Evaluate costs of doing service National Fee Analyzer;

Medi-Cal and Medicare rates

Sliding Fee Scales

Kern Contracts

• Contracted 8/10 • Actively billing

Managed Care System

• Executed 4/25/2012 • Actively Billing Blue Shield

• Clinic Contract • Lab Contract Executed 9/1/12

Tri-West

• Approved March 2012 retroactive to 6/2011; EDI approved 8/12

Medicare

• Submitted to BOS 4/17/12 • Rejected; trying for ancillary contract

Humana

• Approved 5/1/2012 • Awaiting final signatures SISC

• Submitted 1/2012 • Rejected for lack of hospital privileges

United Health Care

• Initial Stages Aetna

• Approved 5/1/2012 • Awaiting contract completion

Anthem Blue Cross

Billable Contract

Credentialing

•CAQH Universal Provider

Data Source

• NPI Numbers

Consent and Disclosure

Insurance Verifier

• Contact the carrier prior to services to verify benefits

• Accurately record authorization

• Relay coverage benefits to patient

Why Documenting is Crucial

• If it isn’t documented, it didn’t happen!

• Errors occur when documenting is inconsistent, incomplete or illegible.

Patient with Insurance

Verify Insurance Coverage with

payer

Sign consents and collect insurance

cards

Explain benefits to patient

Provide services Record services:

Coding and Documentation Collect fees, copays

Bill insurance

Monitor receivables, follow up on any denials

Make Corrections, resubmit bill

Bill

Paid

Front Office

Provider

Cashier

Biller

Kern County Pilot Project

Tdap Project

Billed for Tdap vaccine for 75 subscribers $3,375 at $45/vaccine

$1,470 for administration at $20/vaccine

(contract amount was $10)

Collected $2,989 for vaccine (89%)

Collected $690 for administration fees (92% of contract amount)

Kern County Results

After hiring an Insurance

Specialist:

Total Revenue increased from

$42,961 (7/09 -12/09) to

$491,317 (1/10 – 6/10)

Private Ins. revenue increased

from $6,087 (7/09-12/09) to

between $9,568 and $11,681

for each 6 month period since

1/10.

Clinic Fees (Cash from

patients) increased by over

$40,000 in a 6 month period.

$0.00

$100,000.00

$200,000.00

$300,000.00

$400,000.00

$500,000.00

$600,000.00

Rev

enu

e

Insu

ran

ce

Cli

nic

Ca

sh

Jul-09 toDec - 09

Jan - 10 toJun -10

Barriers

Contracting with private insurance carriers

Staff Resistance

Changing Fee Schedule

Shared Tax ID

Accounts Receivable Reporting

Kern’s Billing Toolkit

Several states have requested copies

Many places are using it!

NYC

Implementation Grants Additional Planning Grants

Houston

Planning Implementation

Duane Kilgus; CDC Stakeholder Meeting, February 1, 2012

Plans for Implementation

“Stay with me

now, people,

because in

step C, things

get a bit

delicate.”

Implementation Process

Seven CA counties

selected to

participate

On-site training

with each site

Post-training

consultation

Billing workgroup

Webinar training

Contra Costa

Humboldt

Mendocino

Long Beach

Madera

San Joaquin

Tulare

San Joaquin County

Paper billing

Medi-Cal, County Plan, Managed Care

Lots of denials; no one to follow up

Problematic clinic flow resulting in many patients not paying

Madera County

No billing, but ready to begin

Fee schedule in process, but not approved

No EMR, but shopping

Very motivated

City of Long Beach

Strong, established billing system, but lots of denials

Fee schedule has built in renewal process and cost of living component, but no sliding scale

Motivated to improve and expand

Humboldt County

Recently upgraded EMR

Very billing savvy

Eager to begin billing 3rd party

Well trained staff, ready to move forward

Contra Costa County

Proactive, looking for training prior to EMR implementation

Currently billing DOT only

Much room for expansion Eager to learn billing for

Lab and IZ services

Tulare County

Currently billing for Lab and FQHC; not yet billing for IZ or TB clinics

Eager to begin billing for mobile clinics

Good billing system in place and prepared to expand

The Trainers

Athina Kinsley, Health Insurance Specialist

Timi Granados, Billing Project

Coordinator

Training Modules

Module #1: Preparing Your Site for

Billing

Module #2: Navigating Contracts and

Enrollments

Module #3: Billing & Coding – Medi-Cal

Module #4: Billing & Coding - Medicare

Module #5: Billing & Coding - Private Insurance

Module #6: Coding & Documenting for Providers

Training Goals

Modify training to meet individual needs

Review Charts to identify consistent errors

Practice dialogues to help employees gain confidence in speaking with patients and health plans

Work hands on with billing team to resolve denials

Follow-up visits to reinforce training and monitor results

Advanced training when needed

Training Schedule

San Joaquin May 14 – 18

Madera June 18 -22

Long Beach July 9 – 13

Humboldt August 7 – 10

Tulare Sept. 18 -21

Contra Costa Oct 23 - 25

Billing Workgroup

Held Monthly

Monthly Topics help establish and improve LHJ billing practices

Share experiences and ideas to create an in-state network of help

CAIR Modifications

California Immunization Registry Enhancements launched

July 1, 2012

System now allows users to

track 317 vs. VFC usage

Looking at Medi-Cal billing within Registry

Challenges

Difficult to get management support in some areas

Lack of project liaison at some sites disrupted continuity and movement of information to other workers

Uniqueness of each county made comparisons difficult at times

Questions?