Medi-Cal Paid Claims Reports Huh???
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Transcript of Medi-Cal Paid Claims Reports Huh???
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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