Billing and Reimbursement Assessment, IPP Region I Wells, Maine June 4, 2012 www.jsi.com

National Assessment Summarize (compare to national)

11/12/2018

11/12/2018

Purpose Of Regional Assessment National Infrastructure Objective Billing = Expectation of multiple federal agencies Safety Net = Payer of last resort Environment = Changing Health Care Goal = Maximize use of Public Health Dollars Unclear what safety net services will exist in future Maximize use of Public Health Dollars Decrease in direct service dollars – increase in surveillance, evaluation, capacity building

Survey Respondents by state 11/12/2018

Survey Respondents by Site Type Lab, FP, STD, SBHC’s, CHC’s, etc. Describe sample and thank everyone for helping

Regional Overview Most billing Medicaid (70%) and other Third Parties (66%) 25-50% services billed to Medicaid 10-25% services to 3rd Parties Other = ????? HALLIE? FP mostly billing, which is good (and unusual for nation) STD & Lab have a way to go

11/12/2018

Cannot Bill Medicaid by Site Type

Cannot Bill Medicaid by State

11/12/2018

Cannot Bill Other 3rd Parties

Cannot Bill Other 3rd Parties 11/12/2018

Do not have Staff Capacity to Bill 11/12/2018

Have a contract with outside company to do Billing And they overwhelmingly were happy with it and found that helpful 11/12/2018

Barriers to Contracting Some companies have refused If MD has no hospital admitting privileges, may be refused Lacking capacity Many have not tried Fallon has refused to contract with FP 11/12/2018

Barriers to Billing Medicaid Capacity and perceived expense of implementation Rates differ greatly Customer service on claims / reimbursement Reimbursement that goes directly into state general funds Dual coverage Clients Dual coverage – that they have to have a rejection from their other payer before medicaid will cover it – “their messed up system” came up a few times….but I thoguht I’d keep that out of the slides….

“As a program that is hoping to establish 3rd party billing for STD, we could use training not only on the mechanics of billing, but on issues that need to be considered when setting up a billing system. How to address EOBs, are we allowed to bill Medicaid for some but not all patients, other rules and considerations that I don't know enough to even ask about. We need 3rd party lab billing 101.” Same with NON lab for many 11/12/2018

11/12/2018

Confidentiality “The concern is there is no confidentiality and we have no control over it.” “We have set up in our practice management system a category for Confidential visits to not bill the insurance carrier if there is a concern” Common and major concern – being worked at on the national level…. Perception that there is No confidentiality – but Medicaid actually does not send out EOB’s so this is not as much of an issue as for 3rd party payers – seems a lot of folks don’t know that…. 11/12/2018

Barriers to Billing Other 3rd Party Payers Many the same as Medicaid Unclear what is covered and how to code to get covered Site not approved as billable site Time prohibitive to “battle” for reimbursement Basically, capacity and perceived expense of implemenation – Site not approved site, etc.

Training Needs 11/12/2018

Training / TA Needs Billing – “none” to “everything” Software / capacity Rate setting Electronic records Everything Coding – “Always - it's complicated and confusing.” Software ICD-10 workshop for common family planning services Billing – range of Training needs – From none to everything Software

More to come….from the STDRHPTTAC