Public Health Billing

Transcription

1 Public Health Billing SCOTT COLEY MS, MPH, CPH IMMUNIZATION BILLING COORDINATOR BUREAU OF IMMUNIZATION, NYSDOH Objectives Convey the importance of public health billing Present the goals of the project Describe public health billing at the outset of this project Discuss public health billing strategies Describe primary means by which NYSDOH and NYSACHO will support LHDs 1

2 Billing Project Background CDC planning grants as part of American Recovery and Reinvestment Act 2009 Survey and data gathering Assessment of 6 volunteer LHDs billing practices Immunization Billing by Local Health Departments: New York State Strategic Plan Elements for Successful Immunization Billing Practice CDC implementation grants: Affordable Care Act, Prevention and Public Health Funds Training, technical assistance and peer network NYSIIS billing data functionality LHD direct aid for billing upgrades Goals of the Project Provide technical resources and assist in information sharing between LHDs that are pursuing reimbursement for immunization services Facilitate LHD shift to comprehensive billing practice Fund LHD efforts to implement or improve billing and fiscal documentation capacity 2

3 Goals Appropriate billing as a strategy to preserve public health services health services LHDs currently billing: ensure that all major compliance issues are addressed LHDs with little or no current billing: Assist in establishing right-sized solutions with complete compliance Changing Environment Growing expense to fully immunize Public funding threats Affordable Care Act will affect the billing calculus Reductions in volume and diversity of services offered by LHDs Billi d fi i l d t ti ti l f Billing and financial documentation essential for LHD survival 3

4 Affordable Care Act and Immunization Coverage: General Expectations First dollar coverage increasing Plans losing grandfathered status Underinsurance for immunizations declining Some co-payment remaining High-deductible health plans Verify insurance coverage to be effective Importance of insurance for LHD clinical services continues to increase Benefits of Implementing Billing LHDs that have the ability to account for the funding of every dose: of every dose: Can efficiently report on public health programs Can document the need for public funds to meet the needs of the population Can show stewardship of public funds Preserve and extend the impact of limited funds Yes, and revenue to offset costs of providing clinical services 4

5 Public Health Billing in New York Currently, LHDs have a wide variety of practices and capacities for billing capacities for billing Identify and advocate for the implementation of basic billing requirements Facilitate the sharing of billing technical expertise Fund LHD upgrades through direct aid How Do You Rate Your Current Billing Capacity? Survey: June 2010, all 57 LHDs responded Needs a lot of improvement Needs Improvement Adequate Good Excellent

6 LHD Fees for Immunization Services Fee = cost of providing the service Insurance dictates reimbursement and out-of pocket costs VFC program limits the maximum allowed fee No cost to LHD, no fee Discounts ensure access: Sliding fee scales Waivers to ensure access Standard metrics for deciding payment source and amount Document fiscal status for each service Appropriate Billing Defined Fee for Service Medicare and Medicaid Bill patient only specified amounts Claim reimbursement Medicaid Managed Care LHD is entitled to reimbursement No contract: NYSDOH determined rate Contract: Contract determines rate Medicare Part D Bill most plans through single web portal without contract Commercial Insurance, Child Health Plus, Medicare Managed Care: Provider contract: claim for reimbursement, collect copays No contract: bill patient Uninsured and Underinsured: Bill patient, apply discounts 6

7 No Managed Care Provider Contract? Public Insurance: Medicaid: bill anyway y Medicare, Child Health Plus: can bill patient, best to refer Commercial Insurance: bill or refer, your choice Some insurers may pay, know before you serve Collect data anyway: Help your LHD in business decisions Use to convince insurers Elements of Successful Billing Revenue Cycle: Processes from first contact to completed reimbursement process. Billing Foundation: The information system capacity, third party relationships and workforce capacity that support the Revenue Cycle 7

8 Front End Intermediate Back End Scheduling & Information Registration Forms Insurance Verification VFC Eligibility Fee Determination Sliding Fee Scale Charge Data Capture Medical Coding NYSIIS Data Entry Claims Processing Explanation of Benefits Remittance Posting Claims Follow-up Adjustments Patient Balance Collection 1. Information System Capacity Health Information Systems Requirements Practice Management Information Systems Electronic Health Record Reporting Capabilities 2. Third Party Relationships Medicare and Medicaid enrollment Provider contracts External billing functions: Clearinghouse and Outsourcing 3. Workforce Capacity Schedule and register patients Billing and collections Electronic funds transfer enrollment Contracting and credentialing Manage revenue cycle processes IT support for software implementation, maintenance and trouble shooting. 8

9 Current Billing Status NYSACHO September 2012 Survey, 53 of 57 LHDs responded. 32 respondents indicated that they were contracted with one or more insurance plans 35 survey respondents submit insurance claims rarely or never 38 indicated an interest in improving their immunization billing capacity Billing Foundation (n=53) 12 Respondents indicated that they did not have the necessary hardware, software or information technology to support billing and 24 were unsure. 28 LHDs indicated that they did not have a satisfactory system for documenting and reporting statistical and financial data. 7 LHDs indicated insufficient personnel for billing, while 13 indicated that their staffing would require comprehensive training to bill effectively. 9

10 Currently Use a Clearinghouse or Medical Billing Company to Submit Claims (n=53) Count Clearinghouse 9 Medical Billing Company 2 Both 1 Neither 41 Billing at Low Volume LHDs Define all clinic services, determine cost to provide and whether clients can be charged Determine sliding fee and fee waiver policies Do you have insurance provider contracts? Purchase vaccine as needed Claim Medicaid reimbursement Other insurance: if no contract, t bill out of pocket 10

11 Right-Sized Approach Build capacity to serve the needs of your client population Provider contracts Purchase of vaccine Billing capacity that fits the services you provide Resource Sharing Consolidate insurance billing operations within the county. Billing system and staff for all clinic services: fewest number of systems possible Contract or MOU with external partner for insurance billing functions Partners: Complete the back end of the billing process Include professional billing organizations, local provider organizations, other LHDs 11

12 Summary Billing for public health services is necessary Appropriate policies ensure that your clients can access services while you are in compliance with a variety of requirements You are not alone. NYS DOH, NYSACHO and your peers can offer assistance for your efforts More information Immunization Billing by Local Health Departments: New York State Strategic Plan ders/docs/immunization_billing_by_lhd.pdf Elements for Successful Immunization Billing Practice. ders/docs/immunization_billing_practice.pdf 12