Building Health Department Capacity to Participate in Third Party Billing and Reimbursement for HIV and Viral Hepatitis Services

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Beverly Walton
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1 Building Health Department Capacity to Participate in Third Party Billing and Reimbursement for HIV and Viral Hepatitis Services Liisa M. Randall, PhD, Consultant HIV Testing in the Emergency Department: Financing and Reimbursement Roundtable Conference November 26, 2012 Washington, DC

2 Mission and Vision Mission NASTAD strengthens state and territory-based leadership, expertise and advocacy and brings them to bear on reducing the incidence of HIV and viral hepatitis infections and on providing care and support to all who live with HIV/AIDS and viral hepatitis Vision NASTAD s vision is a world free of HIV/AIDS and viral hepatitis

3 NASTAD has prioritized billing and revenue generation: Reductions in federal/state/local funds necessitates strategies to diversify funding. ACA: expanded access to insurance increases reimbursement opportunities for preventive services HIV and HCV screening Benefits requirements meet treatment needs of HIV/VH for preventive services

4 Billing and Reimbursement Survey Current billing and reimbursement practices State health department HIV/AIDS and viral hepatitis programs Local service providers supported by the health department HIV/AIDS and viral hepatitis programs; Structural and operational challenges to participation in thirdparty billing and reimbursement; and Future plans for implementing/expanding participating in billing and reimbursement. Fielded 10/9/12, initial close date 10/24/12, follow-up ongoing Follow-up with selected HDs on ED billing practices

5 Billing and Reimbursement Survey Which types of providers are currently seeking reimbursement for any HIV/AIDS or viral hepatitis prevention or care services? Percent (N=25) Community health centers 72% (18) ID/HIV specialty providers 60% (15) Health department clinics 52% (13) Hospital outpatient settings 44% (11) Family planning clinics 40% (10) Hospital emergency departments 40% (10) STD clinics 40% (10) Community based organizations 36% (9) Primary care (not CHCs) 36% (9) Hospital inpatient settings 24% (6) Prenatal/OB clinics 20% (5) TB clinics 20% (5) Urgent care clinics 20% (5) Dental clinics 16% (4) Substance abuse treatment clinics 12% (3) Labor and delivery 8% (2) Correctional facilities 0% (0)

6 Billing and Reimbursement Survey For which of the following services are health department supported providers seeking reimbursement from Medicaid, Medicare or other third-party payers? Percent (N=25) HIV testing 80% (20) HIV clinical services 80% (20) STD testing 64% (16) HCV testing 56% (14) STD treatment 52% (13) Family planning services 44% (11) Medical case management 36% (9) HBV vaccination 36% (9) Risk reduction counseling 12% (3) Patient navigation 8% (2) Prevention case management 8% (2) Adherence counseling 8% (2) Partner services 4% (1)

7 Billing and Reimbursement Survey Barriers Associated with Obtaining Reimbursement for HIV/AIDS and Viral Hepatitis Services (N=32) Rank HIV/AIDS and VH program staff lack of knowledge about billing/reimbursement 1 HD lacks IT infrastructure (e.g., billing software) 2 A majority of clients lack insurance 3 Non-clinical services not eligible for reimbursement 4 HIV/AIDS and VH program lacks capacity to support providers to implement billing/reimbursement 5 Providers lack capacity to follow-up on unpaid bills 6 Challenges in contracting with 3 rd party payers 7 Community-based providers do not use HER 8 Confidentiality/privacy EOB 9 Poor reimbursement rates 10 HD does not use EHR 11 Difficulty in becoming qualified provider 12

8 Figure 8: Medicaid Reimbursement of Routine HIV Testing (N=56) NHPH 2012: HIV Testing Module

9 Billing and Reimbursement Survey: Policy Issues/Challenges Statutes requiring PH services and/or HIV testing be provided free of charge Anonymous testing statutes Legislative or administrative approval of fee schedules Privacy concerns re: EOB Reimbursement rates/coverage of testing and associated services Cost of testing and associated services Varies by setting incentivizes cost-shifting Variable by implementation model, technology MCOs resistant to adding services not already in capitated plans Payer of last resort coordinating public $ for coverage of uninsured Patient co-pay (e.g., amount, collection) Bundled billing/payment Eligibility for payment re: diagnosis HIV testing, associated services not included in negotiated payments Lab services may be covered but not physician, other costs Variable co-payment Payer resistance to including/adding preventive services?

10 Take Away ED s Are a Different Animal Issues are complex and complicated Operational challenges Uptake/support of screening by docs Support of HIV testing/screening by admin Prioritize addressing policy issues with Medicaid, others Coverage of routine testing Capitated rates Preventive services ED s important setting for HIV testing should prioritize sustainability Plan for dedicated funding past 2014 Evaluate cost-effectiveness HDs have steep learning curve 1/3 plan to assess provider capacity, TA?

11 Other NASTAD Activities on Billing and Reimbursement DHAP Billing Work Group: information, materials development, esp. HIV testing. HIV Testing Working Group HIV Health Care Access Working Group/FAPP: advocacy for routine testing, coverage. ASTHO, APHL, NCSD + others: advocacy, strategies to increase HD capacity to participate in 3 rd party payment. Harrison Institute for Public Law, Georgetown: examine legal and regulatory issues associated with health department billing and revenue generation. NACHC + others: TA/CB on HD-CHC collaboration on HIV/AIDS and VH services, including financing/reimbursement, e.g., billing basics webinar.

INSTRUCTIONS. For Using the. Sample Local Survey on Third-Party Billing and Reimbursement for. HIV/AIDS and Viral Hepatitis Services

INSTRUCTIONS. For Using the. Sample Local Survey on Third-Party Billing and Reimbursement for. HIV/AIDS and Viral Hepatitis Services INSTRUCTIONS For Using the Sample Local Survey on Third-Party Billing and Reimbursement for HIV/AIDS and Viral Hepatitis Services The passage of the Affordable Care Act (ACA) coupled with an economic downturn