Bureau of Immunization Assessment & Assurance Missouri Department of Health and Senior Services

Only 19% of Missouri’s LPHAs bill private / commercial insurance companies.

 91.3% bill Medicaid for vaccine administration  86.1% bill Medicaid for client services  83.5% bill Medicare for client services  19.1% bill private / commercial insurance for client services Source: 2012 Infrastructure and Practices Survey

 CDC PPHF grant received 9/2011  Stakeholder meeting 7/2012 ◦ 5 billing models identified  Availity  Health-e-Web (HeW)  Transact  UPP technology  VaxCare / VaxStation  25 LPHAs chosen to pilot billing models ◦ 11/2012 to 4/2013  Insurance Summit 7/2013  Toolkit printed & mailed 9/2014

Billing will allow LPHAs to identify and tap into existing sources of revenue to survive, even thrive, through though economic times when people often need care most.

 Business Process A business analysis should be conducted in order to determine the LPHAs needs.

 Standard Client Survey  How old is the individual requesting the vaccine today?  What is the individual’s county of residence?  Why was the LPHA chosen to get a vaccine?  What kind of insurance does the individual currently have?  Was the individual immunized today?

 Cost Assessment ◦ It is important that the benefits of billing for services outweigh the cost and effort of billing.  Networking will give LPHAs who would like to bill the opportunity to gain best practices and tips from those who are already billing.

The use of a billing model can greatly simplify the billing process.

 Clearinghouse ◦ An intermediary between billing staff and third- party payers  Billing Software ◦ Implements the billing process and assists with the management of day-to-day operations of the agency.  Immunization Service Provider ◦ Provides vaccines, claims processing and patient billing.

 Availity ◦ Web-based clearinghouse with no set-up, monthly or per-claim fees for basic services ◦ LPHA must have contracts with private / commercial insurance companies  HeW (formerly Health-e-Web) ◦ Web-based clearinghouse with no set-up fees and a $79 monthly fee with unlimited transactions ◦ LPHA must have contracts with private / commercial insurance companies

 TransactRx ◦ Web-base clearinghouse with no set-up fees. Charges up to $1.50 per claim fee, which is not paid until the claim is paid by the insurer ◦ LPHA must have contracts with private / commercial insurance companies (company will assist with this)  Upp Technology ◦ Billing software for eligibility verification, claims processing and revenue management on a transactional fee basis ◦ Costs for software set-up $200-$500 each. Per claim fees are also charged ◦ LPHA must have contracts with private / commercial insurance companies

 VaxCare ◦ Third-party immunization service provider that offers vaccines, claims processing and patient billing ◦ Monthly fee of $75 for immunizations administered for the month or $150 for 0-29 immunizations administered for the month ◦ Vaccines & supplies are ordered on an as needed basis at no cost ◦ LPHAs are compensated $10 per immunization for all vaccines excluding influenza, which is compensated at $8 per dose

 Assessing and confirming the qualifications of a licensed or certified health care practitioner  A credentialing application along with supporting documentation must be submitted to the insurance company  Must be credentialed prior to insurance companies paying claims

 The contract is used to accomplish the following: ◦ Establish a legal relationship ◦ Define your responsibilities ◦ Establish the claim filing process ◦ Detail the procedure for payments ◦ Define the fee schedule ◦ Detail regarding co-payments, deductibles, etc.

Although the billing process can be challenging, it is worth the effort to improve the LPHAs sustainability.

 Where will staff perform billing tasks? ◦ Reception desk should be isolated for privacy  Mobile clinics?  Off-site locations?  Personal computer  Internet access

 Receptionist /Intake Specialist ◦ Greeter, collects info, scans cards, gets client signatures, collects forms, & collects payments  Credentialing Specialist ◦ Takes care of all credentialing activities  Billing Specialist ◦ Processes all claims

 Written policies and procedures are vital to the success of billing and should be carefully developed to include all aspects of the process

Billing is the bridge between improving access to care for clients and expanding partnerships between LPHAs and the larger health care system.

 Advantages  Disadvantages  Is the billing model sustainable?  Would you recommend this billing model to other LPHAs?  Additional information

 LPHA identified barriers & solutions