Fee for Service Revenue Generation Survey Results

Transcription

1 Association Of State And Territorial Health Officials 2231 Crystal Drive, Suite 450 Arlington, Virginia (202) Fee for Service Revenue Generation Survey Results The Fee for Service Revenue Generation Survey was administered as a web-based survey from May 3 to May 25, The survey was sent to the chief financial officers of the 59 state and territorial health agencies, with a copy to state/territorial health officials and their senior deputies. Responses were received from 34 states and one territory (Guam), for a response rate of 66% among states and 56% overall. Of the 35 respondents, 29 (82.9%) indicate that they bill Medicaid, Medicare, private insurance or patients for services provided by the state health agency. Of the six agencies that reported that they do not bill for services, two reported that they did not have the authority to bill, and four reported that they did not know whether or not they had the authority to bill for services. When asked about a list of other reasons why they do not bill for services, these agencies indicated that they do not bill because the services they provide are not covered by Medicaid, Medicare or private insurance (one respondent) or that they have other reasons for not billing. o Other reasons cited are: We are not the state Medicaid agency State health department does not provide direct services. Those are done by our contractors. The agency is not a HIPAA covered entity. In order to bill we would need to become HIPAA compliant. We are the last resort Payer. None of the non-billing agencies indicated that any of the following reasons applied to them: o It would conflict with our values. o The law mandates that services must be provided free of charge. o We do not have the capacity to do so. o A high proportion of our patients do not have coverage. o A high proportion of our patients do not have means to pay out-of-pocket. o The health agency would not receive any of the revenue collected through billing anyway. o We believe the costs of seeking payment would be greater than the revenue we would receive from doing so. o We have not been able to become a qualified provider on insurance plans. o We have concerns about privacy. None of the non-billing agencies indicated that they are considering or planning to start billing for services in the future. Of the 29 agencies that do bill for services:

2 All 29 report that they bill Medicaid and/or Medicare. Twenty-one (72.4% of agencies that bill) report billing private insurance. Twelve (41.4% of agencies that bill) report having contractors who provide health-related services and bill for those services. Eighteen (62.1% of agencies that bill) are considering or planning to bill more than they currently do. o These 18 agencies reported the following details on plans and needs for expanded billing practices. Expanded Services Exploring how an electronic medical record system with an automated billing module might help us expand billing to cover all 3rd party payers not just Medicaid/Medicare. Additional services, additional providers Additional services, additional providers Additional commercial insurance plans We have secured a billing vendor who will build a client billing accounts receivable system. Currently working on implementing private insurance billing. Also moving forward with establishing a cost methodology for all services and will seek Board of Health approval to establish new fees for services not currently established by rule. Fee schedules will be aligned with a sliding fee schedule to assure individuals who do not have an ability to pay for services will not be turned away. Public Health Nursing plans to bill vaccine administration fees during the next School Located Vaccine Clinic (flu season). Capacity and Resources Needed Staff; funds to acquire an expanded EMR system; staff training resources. Personnel resources. Intake capacity for programs that have not historically billed. Ability to determine eligibility and report for admin claiming; and potentially either new billing systems or ability to outsource the billing to a 3rd party. Electronic billing capabilities None We have received CDC grants for planning and implementation for billing immunization services. We are currently working on the private insurance component of this grant and plan to expand to all covered clinical services. Additional staff will be required to handle the expanded billing activities and the plan to centralize all billing at the state office. Client database upgrades will be required and hopefully will include an EMR. Consultative services with expertise in coding will also be required. Public Health Nursing needs to have an NPI+3 number assigned by MaineCare.

3 Expanded Services The new Laboratory Information Management System can provide data for billing. This system goes live later this year. Look at collecting better data on population based PH services in order to be able to identify Medicaid eligible recipients. Looking at contracting for additional laboratory services. Exploring ability to bill for services rendered at the State Hospital and the adjacent State Operated residential facility. Also planning to contract with and bill to Tricare. We looking at starting to charge local health departments and safety-net clinics for STD tests if the federal government moves forward with reducing funding to states. Also, we are looking at expansion of fee services for laboratory testing. Bill Medicaid, Medicare and other insurers for clinical services; bill for professional services; increase fees for the few services for which we currently charge; maximize the Medicaid administrative claim; assist community health clinics, critical access hospitals, and state grantees with improved billing and collections (reducing need for state financial support). Contracting with additional third party insurers. We are planning to being billing Medicaid for SCHIP kids. The Help Me Grow and Immunization programs are planning to begin billing Medicaid (as well as private insurance in the case of Immunization) for home visiting and vaccine expenses, respectively. Lab - STD Billing Capacity and Resources Needed Better data collection on some PH services, and increased capacity to bill third party. Revision of Hawaii Administrative Rules must be completed to allow for billing of residential facility and to increase rates. None. 1) Information on requirements for becoming credentialed for each of the major payers. 2) Information on finding and selecting a vendor. None. Internal process need to be worked out. Enhancements need to be made to relevant computer billing systems. Also, the Ohio Dept. of Health is undertaking the planning process to simplify the transition period and integration of its existing health data systems with the Health Information Exchanges required under the Affordable Care Act. It is hoped that one of the benefits will be increased ability to bill the proper entities. Lab - need to address privacy concerns

4 Most report using electronic billing (21, 72.4% of agencies that bill) o Paper billing is still common (12, 41.4% of agencies that bill) o Some agencies use roster (4, 13.8% of agencies that bill) or other (6, 20.7% of agencies that bill) types of billing methods. o Comments regarding other billing methods included: web portal Internal transfer of funds upon valid invoice for hours of service by Public Health Nursing Electronic claims through a contractor (Alhers) The Missouri of Social Services is the State Medicaid agency. DHSS bills DSS for Medicaid administrative claiming. Bureau provides some paper billing and excel spreadsheets to the Department's Central Revenue Unit. They bill Medicaid by submitting information electronically to Medicaid. Health agency staff are most often responsible for both billing (25, 86.2% of agencies that bill) and managing the performance of the billing system (21, 72.4% of agencies that bill). o In four states (13.8% of agencies that bill), billing is done by other state government employees (not in the health agency). o Seven agencies (24.1% of agencies that bill) report using an outside vendor to perform billing services and one reported being in the process of transitioning to an outside vendor. o In 15 agencies (51.7% of agencies that bill), individual programs are responsible for managing the performance of the billing system. o One state (3.4%) reported that the performance of the billing system was managed centrally by state government. o Three states (10.3%) reported that no one performs this function. Fifteen states (75% of those in which billing performance is managed by the state health agency) reported a collection rate or range of collection rates. o Collection rates ranged from 63% to 100%, depending on the specific service and the state. The average collection rate cited was 85%. Funds received through billing most often go to the programs that provide the services: Twenty agencies (69.0% of agencies that bill) report funds going to the programs. Seven agencies (24.1% of agencies that bill) report that funds generated through billing go to the state general fund. Four agencies (13.8% of agencies that bill) report funds going to the state health agency generally. Three agencies (10.3% of agencies that bill) report funds going elsewhere. Comments include: o If revenue is considered program income to a grant, it is applied to that program. Otherwise we attempt to return the revenue to the location that provided the service. o Guam Community Health Center's Revolving Fund o Idaho Bureau of Labs, and eventually Idaho Immunization Program

5 Respondents reported billing for specific services as follows. Service # Billing # Billing # Billing Medicaid Medicare Insurance Adult immunization 11 (37.9%) 14 (48.3%) 7 (24.1%) Childhood immunization 14 (48.3%) 3 (10.3%) 7 (24.1) Travel vaccination 2 (6.9%) 2 (6.9%) 3 (10.3%) Diagnosis of ailments or conditions 10 (34.5%) 8 (27.6%) 10 (34.5%) Home health care services 3 (10.3%) 3 (10.3%) 3 (10.3%) Physical exams 12 (41.4%) 7 (24.1%) 7 (24.1%) Well child preventive care 13 (44.8%) 1 (3.4%) 6 (20.7%) Well adult preventive care 5 (17.2%) 3 (10.3%) 4 (13.8%) HIV testing 17 (58.6%) 6 (20.7%) 7 (24.1%) Hepatitis C testing 13 (44.8%) 5 (17.2%) 5 (17.2%) STD clinical services 16 (55.2%) 7 (24.1%) 9 (31.0%) TB treatment 11 (37.9%) 8 (27.6%) 8 (27.6%) Professional services 2 (6.9%) 2 (6.9%) 2 (6.9%) Lead screening or other environmental testing 15 (51.7%) 1 (3.4%) 4 (13.8%) Newborn screening 11 (37.9%) 1 (3.4%) 5 (17.2%) Inspection of radiological devices 1 (3.4%) 0 2 (6.9%) Other laboratory services 16 (55.2%) 4 (13.8%) 6 (20.7%) Other services 14 (48.3%) 3 (10.3%) 7 (24.1%) Other services cited include: Case Management, Family planning, maternity, behavioral/guidance 0-12 yrs, Nurse home visitation for Childrens First, etc. Nurse Family Partnership Family Planning Services Administrative Services for Home & Community Based Services; Special Health Care Needs; AIDS Case Management HIV Clinical Services Case management Interdisciplinary Team Clinics

6 Behavioral Health Services, Ambulance Transport, Early Intervention Services EPSDT WIC Services Maryland Health Department inpatient facilities costs recovered. Renal dialysis outpatient services Oral Health: dental sealants/fluoride varnish TB Re immunizations: PHD provides vaccine to local health departments who administer immunizations. If the patient has private insurance the county bills the insurer and includes an administration fee. County keeps the admin fee and remits balance to state PH. $s are used to purchase more vaccine. All covered services The professional services state health agencies reported billing for are: Consultation (two states) Provision of data (one state) Facility licensing (one state) Laboratory services were much more often provided by state labs than provided by other labs on behalf of the state. Lead or other environmental testing: 15 states reported billing for state lab tests and 3 states reported billing for tests performed by other labs. Newborn testing: 13 states reported billing for state lab tests and 3 reported billing for test performed by other labs. When asked how national organizations could assist state and territorial health agencies with respect to fee for service revenue generation, agencies responded as follows: Advocate for increased reimbursement: Encouraging the insurance industry to increase their coverage of costs for services would greatly help our communities in receiving the services needed. Advocate to insurance companies to enhance coverage of public health services. By assisting in increasing the collection rate from third party payers. By assisting in updating Fee Schedule to current market rates. Recognition of the Public Health Model for services provided under guidelines and orders using a large public health nursing workforce. Review the currently FMAP methodology to determine if it should be modified to reduce the state burden. Review the impact of the citizenship requirements included in the Deficit Reduction Act. Was there really an issue with non-citizens accessing eligibility or has it just increased administrative burden on the states and access to care to citizens? Assist with advocating for clearer reimbursement methodologies at the federal level.

7 Credentialling public health services has been challenging because insurers are not used to a population-based approach and there is no current provider type that public health fits into easily for Medicaid. Encourage large health plans, e.g., Cigna, Aetna, UHC, BCBS to allow health departments to become contracted providers; work with large, national billing clearinghouse/vendors to develop a streamlined, cost-effective contract so that health departments without the infrastructure to support in-house billing can participate and efficiently increase their collections. Facilitate communication with CMS/insurers Better and more extensive collaboration between Medicaid/other third party payers and health agencies would allow for the maximization of revenue. Help provide access to staff at CMS for appeals. Provide training and information to health agencies Provide training on billing and working with 3rd party payers. Provide current laws and billing techniques to states. Suggestions for typical codes used for public health services Provide training for coders, and on processes and procedures for billing By educating health departments on billable services and providing data on what services other states are billing for and guidance on how to implement these initiatives to increase Medicare/Medicaid revenue. Provide more guidance and training for state laboratories Lab - provide trainings on billing/reimbursement/insurance practices/requirements/regulations so staff are familiar with process and rules that govern billing. Oral Health - provide information on reimbursement mechanisms for state health agency along with other parts of state government such as Medicaid, Comptroller's Office Provide capacity building assistance Provide grants to build capacity to establish or enhance billing. Assist with building State capacity to generate revenue. Assist with efforts to establish payer reimbursement for prevention services. Facilitate communication between the third party payers and the health agency, develop systems for eligibility verification with similar requirements, such as data access, use of web portal to get service authorization, resubmit denied claims, upload medical record documentation. Facilitate group purchasing of professional billing services. Secure funding for electronic ordering of tests so that billing information is captured electronically without additional manual data entry.

8 Facilitate sharing of best practices Through networking and sharing of best practices. Share services other states are successfully billing. Share best practices in billing and collections. Share what other state health agencies are doing in order to maximize revenue from third party payers for the services provided.