Medi-Cal Paid Claims Reports

Huh???

Joanne Roberts, PHNPerinatal Services Coordinator

Los Angeles County

November 14, 2013

Objectives

Perinatal Services Coordinators will:•Be able to interpret the information on the Medi-Cal Paid Claims Report•Understand why the Paid Claims Report is an essential component of quality assurance and monitoring

What Is It?• Report of claims paid by

Medi-Cal for a 6-month period: Jan-June and July-Dec

• Fee-for-service only• Does not include Medi-Cal

Managed Care, FQHC, RHC, IHC

3 Separate Reports

• Delivery Only• Non-Delivery Only• CPSP Only

Non-Delivery & Delivery Only

• Non-Delivery: prenatal, postpartum, and global codes

• Delivery Only: deliveries (excluding global billing codes)

• Use to identify/recruit new CPSP providers

CPSP Report

• Health education, nutrition, and psychosocial services

• CPSP bonuses: early entry and 10th visit

• Monitor CPSP provider activity

What’s in the CPSP Report?

• County Name• Provider Type Code• Provider Specialty Code• Provider Legal Name• Provider Address, City, Zip Code

What Does It Tell Me?

• Who’s billing CPSP in your county?– Do you recognize all the

names?– Non-CPSP providers?– Approved providers missing?– Different address?– Approved providers with

unknown sites?

What’s in the CPSP Report?

• “Claim Count”– Number of services

• “Total Billed Quantity”– Units of service

• Example: – Claim count (# of services) = 50– Total billed quantity (# units) = 147

Claim Count & Quantity

• Compare the numbers• Quantity usually 2-3 times more than

Count• When Count = Quantity

– Only 1-unit services are billed– Usually means bonuses only– Could be billing error

Now for the Money!

• Does the total amount paid fit with the provider type?– Is small solo practice making

$200,000 for CPSP only– Is large hospital clinic making

only $10,000

Red Flags

• Providers reimbursed more than expected– Misunderstanding– Intentional overbilling (fraud)– CPSP done at multiple sites

billed from one site (other sites may not be CPSP approved)

Red Flags

• Providers reimbursed less than expected– Misunderstanding by provider

staff – Biller not billing correctly:

“Medi-Cal doesn’t pay.”

Hospitals• Lower than expected

reimbursement?– Billing departments and clinic staff

don’t communicate– Clinic staff may not mark correct #

units– Billers submit as claims “Quantity =

1” for all services, regardless of # of units provided

– Hospital computers programmed to discard any claim below a certain amount ($25, $50)

What Do I Do With It?

• Review prior to calling/visiting any fee-for-service provider

• Ask provider how billing is going?

• Compare response to paid claims amount

Example #1PSC: Hi, I’m calling to schedule your annual CPSP quality assurance review.

Office Manager: Oh, we’re not doing CPSP right now.

PSC: Really, because the report I’m looking at shows that you billed $187,000 just for CPSP services between January and June of this year.

Office Manager: That’s impossible!

Example #2PSC: Hi, I’m calling to schedule your annual CPSP quality assurance review. How’s everything going? Are you billing for CPSP?

Office Manager: Everything’s great! We’re seeing a lot of CPSP patients and the billing is fine.

PSC: Are you sure because I have a report that shows you haven’t been reimbursed anything in the last 6 months.

Office Manager: (silence)

Let’s Look at the Report

Paid Claims Report Jan-Jun 2013

Volunteer needed!

Next Steps

• Update the billing codes used in the CPSP, Non-Delivery, and Delivery Only reports

• Rename the column labels to be more self-explanatory

• Continue relationship between MCAH and Medi-Cal to ensure uninterrupted availability of the Paid Claims Report

Conclusion

• Paid claims are invaluable to PSCs

• The report’s not that complicated once you know what you’re looking at

Billing Resources

• Medi-Cal: www.medi-cal.ca.gov– Provider Manual, Bulletins, Learning

Portal, contact Regional Representative

• ACS/Xerox (Medi-Cal Fiscal Intermediary)– Telephone Service Center (TSC): 1-800-541-

5555– To leave a message for a Regional

Representative, call the TSC then follow the prompts 11, 15, 14

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Thank you!

Joanne Roberts, PHN(213) 639-6427

jroberts@ph.lacounty.gov

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