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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?