1© WSU Community Engagement Institute, (316) 978-3843

Improving Immunization Billing in Local Health Departments:The Story of a CDC Immunizations Grant

AAron Davis, MBAProject ManagerCenter for Public Health InitiativesJune 9, 2016

aaron.davis@wichita.edu

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The story of a CDC Immunizations Grant

• What we did• How we did it• Why we did it• Lastly….what can you gain from it?

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Agenda

1. Grant Purpose & Background2. Discuss the three projects of the grant3. Goals & Accomplishments4. What we learned5. Guidance moving forward

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Project Background

Implementation of Strategic Plans for Billing for Immunizations Services in Health Department Clinics

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Intent of the Grant

• Problem Statement:

– Insured patients are accessing immunization services at public health departments for free or a nominal administrative fee.

• Purpose:

– To enable public health departments to bill health insurance plans, with the intent of capturing maximum immunization service delivery fees.

• Outcomes:

– Short Term: Public Health Departments able to begin/expand/or continue to capture reimbursements for immunization services.

– Long Term: Greater reach of immunization efforts.

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Background

• 2012 Kansas Immunization Program award for “CDC Immunizations Billing Planning Grant”– Contract with KFMC– Surveys of billing practices across the state– Pilot Project for measuring effects of Certified Coders

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KFMC Recommendations

1. Biller specific coding manuals2. AAPC Coding Training (will also cover ICD-10)3. Electronic Health Record Pilot Program

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Background

• 2014 Kansas Immunization Program award for CDC grant: “Implementation of Strategic Plans for Immunization Services in Health Department Clinics”– Contract with Center for Public Health Initiatives of the

Community Engagement Institute at WSU

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October 2014

1. Billing Manual

2. LHD specific Training

3. PMS/EHR Pilot

4. Continue Survey

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Billing & Coding Manual

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Billing & Coding Manual

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Kansas Local Health Department Clinical Services

Billing & Coding Guide

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Design Team has included…

• Johnson County HD• Harvey County HD• Harper County HD• Pottawattamie County HD• Riley County HD• Franklin County HD• Ellsworth County HD• Shawnee County HD• Haskell County HD• Reno County HD

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Clinical Services Coding Guide

Billing Policies & Procedures

• Section 1: Provider Enrollment• Section 2: Insurance Eligibility & Verification• Section 3: Coordination of Benefits• Section 4: Claims Submission & Resubmission• Section 5: KMAP

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Clinical Services Coding Guide

Methodologies & Common Coding

• Section 6: Immunization Services• Section 7: Child Health Services• Section 8: Women’s Health Services• Section 9: Adult Health / Miscellaneous Services• Section 10: Laboratory Services• Section 11: Appendices

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Clinical Services Coding Guide

Where to find it?

• http://www.kdheks.gov/olrh/download/KS_Billing_Resource_Manual.pdf

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Lessons Learned

• Sustainability is everyone's first question• Understanding what the codes mean and how to use

them VS. knowing other departments use them

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Kansas Local Health Department Specific Coding Training

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KS LHD Coding Training

World of Medical Coding

What LHDs Code

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KS LHD Coding Training – June 2, 2015

• First meeting of LHD Billers from Across the state

• Great Discussion• 80+ LHDs represented• Sadly, the training missed

the mark

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KS LHD Coding Training – Sept 1&2, 2015

• Online webinar• 90+ LHDs represented• Training was better, but

still didn’t answer all the questions we wanted it to

• Videos still available online

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Lessons Learned

• Why is this so difficult?

• How do we get this right in the future?

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Practice Management Software & Electronic Health RecordsKansas LHD Pilot Program

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Quick Definitions

• Electronic Health Records (EHR)• Practice Management Software (PMS)• Billing Software• Hybrid Systems• Outsourced Billing• Clearinghouse

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Pilot Project Benefits

• Training and guidance from experienced EHR consultants• Technical Assistance from WSU’s CPHI• Financial assistance (75% of a system, up to $10,000) for

PMS/EHR• Peer Learning Workgroup

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Criteria for Participation

• Must have >40% of total billed revenue from Immunizations Services OR must be the sole immunizer in the county for adults and/or children.

• Must be a Local Health Department that has not signed a contract with an EHR company in the last 2 years.

• Must be able to provide baseline data for application.

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Selected Counties

• Populations ranged from 2500 to 35000• FTEs range from 2.5 to 15• Annual Billing income from all sources ranges from

$35,000 to $350,000• # of annual unduplicated encounters range from • 900 to 6800

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Summary of Project

•EHR Review and Implementation Training (Synovim)•Demos of 11 vendors, discussions with more•Presentation from a fellow LHD who had implemented a system

•Weekly calls to discuss issues and questions•Monthly reports to share where departments were in the process

•Surveys, surveys and surveys

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Timeline of Pilot

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Timeline of Pilot

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Tools for Implementation

1. Team Charter2. Department Workflow Tools3. Goals Document4. Implementation Timeline &

Project Plan5. IT Evaluation6. Chart Migration Worksheet7. Data Entry Template

Guidance Document

8. Vendor Demo Script9. Vendor Evaluation Tool10.Staff Computer Knowledge

Evaluation11.Patient Satisfaction Survey12.Post Implementation

Evaluation

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Review and Evaluation of systems

Reviews and discussion of some kind completed with:

• Nightingale Notes• Patagonia• Insight by Netsmart• Smart Health Claims• Athena Health• Sevocity• HealthPac

• Healthcare First• Mitchell & McCormick• Allscripts• eClinicalWorks• KIPHS• CDP

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Vendor Differences

• Public Health vs. Private Practice focus• User Interface (friendly to use/navigate)

– Clinical– Financial– Administrative/reporting

• Training and Customer Service• COST!

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Vendor Selections

• Patagonia Health: 5 • Nightingale Notes by Champ Software: 4• AthenaHealth: 2

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Implementation

1. Set up data elements, work flow, templates & pathways2. Training on the system3. Testing of the system (practice)4. Adjust data elements, work flow, templates

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WebIZ connections

• As of today, zero systems are connected• Two are in the beta testing (getting connected)• All should be done by the end of summer

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Surveys & Results

• Financial Data– 2014 (prior implementation)– 2015 (during implementation)– 2016 (after implementation)

• Staff Transitional Survey– Grant Process– Internal changes

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Surveys & Results - Financial

2014 2015 2016

Total Encounters 33,214 38,713

Total Billing Rev $1,531,268  $1,558,037

Total Imm Encounters 20,155 23,365

Total Imm Billing Rev $1,121,130  $1,174,506 

Results for 9 pilot sites

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All Billing Revenue Across 2 years

 $‐

 $20,000

 $40,000

 $60,000

 $80,000

 $100,000

 $120,000

 $140,000

 $160,000

 $180,000

 $200,000

2014 Q1 2014 Q2 2014 Q3 2014 Q4 2015 Q1 2015 Q2 2015 Q3 2015 Q4

Pilot 1 Pilot 2 Pilot 3 Pilot 4 Pilot 5 Pilot 6 Pilot 7 Pilot 8 Pilot 9 Pilot 10 Pilot 11

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All Billing Revenue Across 2 yrs – 2 pilots

 $‐

 $10,000

 $20,000

 $30,000

 $40,000

 $50,000

 $60,000

 $70,000

 $80,000

 $90,000

2014 Q1 2014 Q2 2014 Q3 2014 Q4 2015 Q1 2015 Q2 2015 Q3 2015 Q4

Pilot 2 Pilot 4 Pilot 5 Pilot 6 Pilot 7 Pilot 8 Pilot 9 Pilot 10 Pilot 11

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Staff opinions Survey @ 3 months in

• 37 responses from 10 LHDs– 13 Clerical/Administrative– 15 Clinical– 3 Clinical/Administrative– 6 Other

• Whole group Vs each vendor– Only one response from AthenaHealth users

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Staff Opinions - Pilot

Please indicate your level of agreement with the following statements, "Being part of the CDC EHR pilot helped with:”1. Reviewing EHR options available.

2. Evaluating needs and system requirements.

3. Making a decision on what system to purchase.

4. Contract negotiations.

5. Being comfortable with the price of the system.

6. Creating a forum to discuss issues and questions with other departments.

7. Effectively implementing the new EHR system.

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Staff opinions (3 months in) All Staff

Please rate your level of agreement with the following statements regarding your use of the new EHR system.1. The EHR has made my job easier compared to our previous systems/processes.

2. The calendar function of the EHR is better than our old calendar system.

3. This EHR clearly displays the information I need without unnecessary information or other clutter.

4. This EHR allows me to complete tasks efficiently, without seemingly unnecessary steps.

5. Learning to use this EHR was easy.

6. Our EHR vendor provides excellent support (for instance, fixing bugs quickly, offering useful training, and providing answers in a timely manner).

7. I enjoy using this EHR. I would recommend our current EHR to my counterparts in other health departments.

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Staff opinions (3 months in) Admin.

Please indicate your level of agreement with the following statements regarding your use of the new EHR system. 1. Scheduling patients is easier than it was in our previous system.2. Looking up patient information is more efficient.3. Documentation of clinical information is more detailed and

thorough.4. Billing is easier than it used to be compared to our old

system/process.5. Time spent submitting insurance claims has decreased.6. The overall billing process of the department has improved.

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Staff opinions (3 months in) Clinical

Please indicate your level of agreement with the following statements regarding your use of the new EHR system.1. This EHR helps me see more patients per day than I could with paper

charts. Disagree

2. I can document care easily and efficiently. Neutral to Disagree

3. Documentation of clinical information is more detailed and thorough. Neutral

4. Using the EHR has improved my ability to make decisions about patient care. Disagree

5. This EHR helps me avoid making clinical mistakes. Neutral to Disagree

6. This EHR helps me focus on patient care rather than on the computer. Disagree

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Staff opinions (3 months in) Comments

• Because we are still learning the EHR it is still hard to measure the progress in understanding other staff role and responsibilities. Communication between staff has increased measurably.

• Many of the steps are cumbersome and documented several times. A lot more time is spent on documentation than the past.

• Took some frustrations to adjust and get it set up properly

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Cost/Benefit?

Thanks AHIMA!

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Cost/Benefit?

• Compare your workflows today compared to workflow with the EHR– You have to have clear goals and expectations!

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Cost/Benefit?Outline Current Costs & Future Goals for:• Increased productivity (chargeable)• Increased productivity (flexible) • Reduce data entry• Increased charge capture & timely filing• Software maintenance & support • Filing, retrieval, and storage of paper charts• Mailing costs• Write-off of bad debt• Denial rates• No Show rates• Reporting and analysis

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How are things going?

• In the short 15 month period we have seen:– 3 new directors– 4 changes in lead billing staff– I have heard several users say they wish they could

go back to their old system / way of doing things– 11 departments have said they know this will be

great once the kinks get worked out

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Grant TargetsDid we meet our goals? What’s next?

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October 2014

1. Billing Manual

2. LHD specific Training

3. PMS/EHR Pilot

4. Continue Survey

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Practice Management Software & Electronic Health Records

Guidance/Toolkit

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Landscape of Health IT in KS LHDs

• What are people using?• What is Meaningful Use and does it matter?• Some EHR tools are available…but…

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Meat & Potatoes and my 2 cents…

1. Stark realities you need to accept2. Assessing department capacity & staffing needs3. Features & benefits4. How to select systems5. Costs, timelines & steps

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Stark Realities you need to accept

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Stark Realities you need to accept

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Assessing Capacity

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Assessing Capacity

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Staffing Needs (Tech Savvy, leadership, buy-in)

• First, you MUST have a tech-savvy champion• Second, you MUST have a back-up• Third, you MUST get everyone to move forward

together.

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Features & Benefits

• General Usability• Patient Demographics• Scheduling• Consents & Authorizations • Patient Charting & History• Program specific data

collection• Order Entry and Processing

• Medication Inventory• Quality Improvement• Billing• Reporting• Privacy and Security• Vendor Implementation and

Support• System Connectivity

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How to select systems

• Selection Criteria Matrix• Do Demos with multiple systems• Don’t purchase a system until you see it live in action

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Costs

• COSTS VARY! By vendor and with the same vendor.• Caveat – Company, Athena, licenses, training,

discounts, hardware & support, home health and other add-ons.

• Start-up Costs– 3-5 staff ($9000-$11,250) (average of $9,800)– 6-15 staff ($9200-$13,500) (average of $11,200)

• Annual Fees – 3-5 staff ($5,760-15,600) (average of $9,924) – 6-15 staff ($5,040-15,600) (average of $9,444)

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Timelines & Steps

• Phase 1: Assess Your LHD’s Readiness• Phase 2: Approach Planning• Phase 3: Selecting an EHR• Phase 4: Conduct Training and Adjust System• Phase 5: Implement EHR and Adjust System• Phase 6: Continue Quality Improvement

(adjust how you use it)

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68© WSU Community Engagement Institute, (316) 978-3843

Improving Immunization Billing in Local Health Departments:The Story of a CDC Immunizations Grant

AAron Davis, MBAProject ManagerCenter for Public Health InitiativesJune 9, 2016

aaron.davis@wichita.edu