1. Billing at the Milwaukee Health Department Clinics: An Analysis of Potential Revenue Gains Presented by: Jamie Aulik Victoria Deitch Emily Pope Eric Thomasgard La Follette School of Public Affairs May 5, 2006

2. Project Introduction Budget and Management Division, Department of Administration asked the La Follette School to analyze billing practices at the Milwaukee Health Department Clinics Over the past four months we have visited the clinics, interviewed MHD staff, analyzed MHD data, and interviewed officials at other health departments

3. Milwaukee Health Department Clinics The MHD operates six clinics for the provision of health services to the uninsured and underinsured In our analysis we investigated four clinics: Walk-In, Family Health, Tuberculosis (TB) Control and Refugee Health, and HIV/AIDS and STD These clinics are located at three health centers: Keenan, Northwest and Southside

4. Services and Billing These clinics offer a variety of services including immunizations, pregnancy testing, prenatal care, health checks, TB testing and therapy, and HIV/AIDS and STD testing and treatment Currently, the MHD bills for services provided to Medicaid clients Services provided to clients without Medicaid insurance are free of charge

5. Current Billing The MHD has MOUs with three Medicaid HMOs which allows them to bill for a limited set of services In 2005, we estimate that the MHD billed Medicaid $31,700 for immunizations, pregnancy tests and health checks

6. 2005 Billing Estimates Source: Calculations based on data from City of Milwaukee Health Departments’ clinic’ flow sheets, Analysis of Services, Immunization Consent Analysis, billing summary, and Wisconsin Department of Health and Family Services Medicaid maximum fee rates.

7. Potential Sources of Revenue Loss Clients do not accurately report Medicaid status because they are unaware or are confused by the intake form Problems at the clinics, MHD main office, or Medicaid HMOs Medicaid plan does not cover clinic services

8. Sources of Current Revenue Losses Source: Calculations based on MHD Immunization Consent Analysis and Our Medicaid Revenue Estimates

9. Policy Evaluation Criteria Maintain level of service to uninsured and underinsured Increase clinic revenue Implementation feasibility

10. Policy Alternatives 1. Changes to the billing process 2. Increase billing for services by implementing monthly audits 3. Increase billing for services by implementing incentives 4. Expand existing MOUs to cover additional services 5. Investigate MOUs with private insurance providers 6. Charge uninsured and privately insured a flat fee

11. Alternative 1: Changes to the Billing Process Use billing checklist Refer all uninsured clients to Medical Assistance Outreach Program (MAOP) Change intake form from “Medical Assistance” to “Medicaid” and “Medicare”

12. Evaluation of Alternative 1 Maintain Level of Service to Target Population: High Increase Revenue: High Feasibility: Medium

13. Alternative 2: Increase Billing Through Monthly Audits All billing forms and checklists sent to MHD main office Create new clinic flow sheets Compare billing forms to total number of services provided

14. Evaluation of Alternative 2 Maintain Level of Service to Target Population: High Increase Revenue: High Feasibility: Medium

15. Alternative 3: Increase Billing By Implementing Incentives MHD does not currently receive any benefit from billing We propose that some portion of clinic revenues be returned to the clinics Must be approved by Milwaukee Common Council Marion County (Indianapolis) and King County (Seattle) receive 100 percent of reimbursements for services

16. Evaluation of Alternative 3 Maintain Level of Service to Target Population: High Increase Revenue: Medium Feasibility: Medium

17. Alternative 4: Expand Existing MOUs to Cover Additional Services Current MOUs permit the MHD to bill Medicaid HMOs only for certain services We propose that the MHD expand these MOUs to include STD testing and treatment provided at the Keenan Health Center STD testing and treatment will continue to be offered anonymously at the Southside STD clinic HIV/AIDS testing at the Keenan clinic will not be billed

18. Alternative 4: Revenue Estimates If the MHD began billing for STD testing and treatment, it could significantly increase revenues

19. Alternative 5: Sign MOUs with Private Insurance Providers MHD does not bill private insurance providers 13 percent of clinic clients have private insurance MHD could increase its revenue by billing private insurance Currently, Columbus has a contract with one private insurance company King County (Seattle) bills private insurance company without a contract

20. Alternative 5: Revenue Estimates

21. Alternative 6: Charge a Flat Fee If a client does not have Medicaid insurance, clinic services are provided free of charge Health departments in other cities charge uninsured and privately insured clients These fees are either fixed or based on a sliding scale If the MHD imposed a $5 flat fee for services, revenue would increase between $20,300 and $37,300

22. Evaluation of Alternative 6 Maintain Level of Service to Target Population: Low Increase Revenue: High Feasibility: Medium

23. Recommendations Based on our analysis, we recommend: Changes to the billing process Increase billing for services by implementing monthly audits Expand existing MOUs to cover additional services Investigate MOUs with private insurance providers