1. Billing and Reimbursement Assessment, IPP Region I
Wells, Maine
June 4, 2012

2. National Assessment
Summarize (compare to national)

3. 11/12/2018

4. 11/12/2018

5. 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

6. Survey Respondents by state
11/12/2018

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

8. 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

9. 11/12/2018

10. Cannot Bill Medicaid by Site Type

11. Cannot Bill Medicaid by State

12. 11/12/2018

13. Cannot Bill Other 3rd Parties

14. Cannot Bill Other 3rd Parties
11/12/2018

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

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

18. 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

19. 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….

20. “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

21. 11/12/2018

22. 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

23. 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.

24. Training Needs
11/12/2018

25. 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

26. More to come….from the STDRHPTTAC