sustaining your organization through third-party …...revenue cycle management, and electronic...

SUSTAINING YOUR

ORGANIZATION

THROUGH THIRD-PARTY

BILLING

Jeffery M. Erdman

Assistant Director for Programs and Compliance

Illinois Public Health Association

Illinois HIV/STD Conference, October 2016

WHY BILL THIRD-PARTY PAYERS FOR

HIV TESTING AND OTHER HIV SERVICES?

While health departments (HDs), community-based organizations (CBOs), and other healthcare providers are some of the most common providers of HIV testing and other HIV services, many of them have not developed capacity to bill public or private payers/health plans.

In a 2016 HIV Testing and Billing Report developed by the National Alliance of State and Territorial AIDS Directors (NASTAD, only half of health departments who deliver HIV testing services have implemented or are planning to implement third-party billing.

The National Association of County and City Health Officials (NACCHO) reported in recent years that 48 percent of U.S. public health departments reduced or eliminated services and jobs.



Illinois is in the midst of its worst budget crisis in

history, having gone 12 months without a State

budget and having only a stop-gap budget in

place through December 2016.

Additionally, Illinois is seeing a reduction in HIV

grant dollars year after year from federal

partners (CDC), and providers are now operating

under extremely challenging funding models

(Fee-for-Service).

This fiscal chaos is wreaking havoc among

organizations who must look to new models for

long-term sustainability.



HIV providers need to maximize revenue capture

to sustain their organizations and to continue to

provide essential HIV services in an era of

dwindling public funding and uncertain economic

times.

The true benefit of billing third-party payers for

HIV organizations is that this revenue is not

dependent on grant or State funding, which can

have stifling stipulations and is notorious for

significantly delayed payments.



HIV providers often offer safety net coverage:

ensuring that low-income clients, many newly

insured under the Affordable Care Act

(ACA)/expanded Medicaid, have access to HIV

testing and other HIV services.

More newly insured clients means more

billing potential and new revenue

opportunities to maintain staff/maintain

services/expand services to other

vulnerable populations (i.e., HIV case-

managed clients).

HIV SERVICE COVERAGE UNDER THE ACA

The ACA mandates Essential Health Benefits be covered by insurers, which include HIV/STD tests and other preventive services.

The U.S. Preventive Services Task Force (USPSTF) has given HIV screening an “A” rating, meaning clinicians should regularly screen for HIV and this service should be covered by Medicaid, Medicare, and commercial insurers without a “patient due balance.”

Similarly, the ACA defines Essential Community Providers of healthcare services in communities, which include local health departments, Ryan White providers, STD/HIV clinics.

HIV SERVICE COVERAGE

Health departments, CBOs, and other healthcare providers offer a variety of other essential HIV services, beyond HIV testing, which may be covered by public and private payers.

These services include HIV/STI counseling, PrEP initiation counseling, risk reduction counseling, medication adherence counseling, behavioral counseling to prevent STIs, care coordination and case management, condom distribution, etc.

Insurance companies pay for these services that are described by a CPT code and performed by a licensed provider or performed under the supervision of a licensed provider. Services are paid based on a fee associated with each CPT code.

KEY ILLINOIS PAYERS

FOR HIV SERVICES

Aetna

Anthem

BlueCross BlueShield

of IL

Cigna

Coventry

Employers Coalition on

Health

Health Alliance

Health Link

HFN

Humana

Illini Care

Meridian

Meritain

Molina Care

Northern IL Health

Plan

Right Choice

United Healthcare

Wellpoint

HOW TO BILL THIRD-PARTY PAYERS FOR

HIV TESTING AND OTHER HIV SERVICES

An organization seeking to bill third-party payers for HIV testing and other HIV services delivered to insured clients must first be credentialed with the third-party payer.

Credentialing is the process of establishing the qualifications of the healthcare provider with the insurance company.

The insurance company will examine the credentials of the healthcare provider’s medical director. This is usually done with each third-party payer and is updated annually.

This process is lengthy and there are many billing vendors and online/web resources that can assist with this process.



An organization seeking to bill third-party payers for HIV testing and other HIV services delivered to insured clients must next be contracted with the third-party payer.

Contracting is the process of developing an agreement between the healthcare provider and the third-party payer (insurance company).

The agreement, or contract, allows the healthcare provider to be recognized as an in-network provider and to be reimbursed for claims submitted for services delivered to insured clients.

This process is also lengthy and there are many billing vendors and online/web resources that can assist with this process.



An organization seeking to bill third-party payers for HIV testing and other HIV services delivered to insured clients must finally code and bill the delivered services to be submitted to the third-party payer.

Coding is the process used by the healthcare provider to classify and define the services provided to the insured clients, based on predetermined CPT codes for the purpose of billing.

These codes are processed for payment on a billing claim to the insurer by a billing and coding specialist.

This process can also be lengthy and there are many billing vendors/billing and coding specialists and online/web resources that can assist with this process.

IPHA’S RESOURCES AND EXPERIENCES

WITH THIRD-PARTY BILLING FOR

PREVENTIVE HEALTH SERVICES

IPHA’s First Third-Party Billing Project:

Prevention and Public Health Fund (PPHF)

Project to Implement Reimbursement for

Immunizations in Public Health

Department Clinics (CDC funded).

Pilot Phase of Project: September 2012 –

September 2014.

Implementation Phase of Project: October 2014-

December 2016.

IPHA IMMUNIZATION BILLING

PROJECT COLLABORATIVE

By contracting with a third-party billing vendor –

CDP, Inc. of Romeoville, Illinois - specializing

in credentialing, contracting, billing and coding

(revenue cycle management), and electronic

medical records (EMR) implementation, IPHA

formed a billing collaborative of more than 30

local health departments (LHDs) across the state

to bill for immunizations and other preventive

services for clients covered by Medicaid, Medicare

and approximately 40 insurance carriers in

Illinois.

IPHA IMMUNIZATION BILLING

PROJECT COLLABORATIVE

At the outset of the project, the participating LHDs projected that total revenue earned over two years from billing Medicaid and commercial insurers would be $420,000.

At the end of the project’s second year in 2014, total reported revenue for these LHDs from billing Medicaid and commercial insurers was $911,000 – an increase of 116 percent from projected numbers!

As of October 2016, total reported revenue is more than $2 million and 84 LHDs in Illinois are now billing third-party payers for preventive health services.

EXPANDING THE BILLING COLLABORATIVE

TO COVER HIV TESTING SERVICES

Beginning January 1, 2016, the Illinois Department of Public Health (IDPH), the Illinois Public Health Association (IPHA), the Public Health Institute of Metropolitan Chicago (PHIMC), and Custom Data Processing, Inc. (the third-party billing vendor) partnered on the CDC Category B third-party billing redirection initiative to:

Support a minimum of 3 Local Health Departments and 3 Health Care Providers within Illinois outside the City of Chicago which currently bill Medicaid and private insurance for other health services to initiate Medicaid and insurance billing specifically for Routine HIV Testing by 12/31/2016 through technical assistance and training.

Begin the process of credentialing to generate Medicaid Billing with a minimum of 3 Local Health Departments and 3 Health Care Providers within Illinois outside the City of Chicago not currently credentialed or enrolled for Medicaid billing by 12/31/2016.

Assist a minimum of 5 Local Health Departments and/or 5 Health Care Providers within Illinois outside the City of Chicago to implement Electronic Medical Records (EMR) and/or revenue cycle management (RCM) systems suitable for billing and reimbursement which currently lack such systems.

OTHER HIV BILLING COLLABORATIVE

GOALS

Additional goals on the HIV Third-Party Billing Project include:

Conducting webinars to include: credentialing and contracting, billing and coding, and RCM/EMR concepts. All of these webinars are archived on the IPHA website for free viewing by any interested party.

Conducting credentialing and contracting between healthcare providers and insurers to credential licensed and non-licensed staff and to incorporate HIV testing and other HIV services into contracts.

Planning and implementation of billing systems and/or electronic medical records.

Conducting project and revenue evaluation.

THE BILLING VENDOR

FOR THE HIV BILLING COLLABORATIVE

In NASTAD’s 2016 HIV Testing and Billing Report, the top two challenges for health departments in implementing third-party billing for HIV testing were program staff lacking knowledge of billing and program staff lacking the capacity to support third-party billing implementation.

Due to similar capacity challenges early on in Illinois, the third-party billing projects secured the expert services of a billing vendor:

CDP is a Romeoville, Illinois-based firm with 30 years of public health experience specializing in credentialing, contracting, revenue cycle management, and electronic medical records implementation.

CDP’s EMR solution, ezEMRx, is a certified stage 1 and stage 2 Meaningful Use/public health-ready EMR solution. The system includes a full revenue cycle management system that is fully integrated with EMR. Other features include insurance eligibility verification, scheduling, inventory management, claims “scrubbing,” and various other practice management services.

OTHER HIV BILLING COLLABORATIVE

PARTNERS

More than 20 LHDs and CBOs across Illinois, representing rural and urban communities, have joined or are working to join the HIV Third-Party Billing Project.

Approximately 10 healthcare systems across Illinois, representing large systems (Loyola University Medical Center, Southern Illinois Healthcare Foundation) and smaller systems (Open Door Health Center) have joined or are working to join the project.

A Stakeholder Advisory Group (SAG) comprised of LHDs, CBOs, healthcare providers, insurance companies, healthcare product manufacturers, and the project team meets quarterly to guide the direction of the project and to share resources.

FIRST YEAR SUCCESSES FOR THE HIV

BILLING COLLABORATIVE

Many Illinois local health departments and healthcare providers are now billing third-party payers for HIV lab/testing services; continued project work will focus on billing for the patient visit, HIV test counseling, PrEP counseling, condom distribution, and other related services.

Nearly all Illinois providers are contracted with Medicaid; continued project work is focusing on Medicaid Managed Care (MCO) contracting.

More than 30 providers across the HIV and Immunization Billing Projects have now implemented electronic medical records and/or billing systems; implementation work continues.

“The next frontier”: Getting third-party payers to recognize non-licensed, non-CHW peer staff and to expand the list of billable HIV services (surveillance?)

HOW TO JOIN THE HIV OR

IMMUNIZATION BILLING PROJECTS

There is still time to join both the HIV Billing

and Immunization Billing Projects!

Available grant funds on these projects can

assist organizations with contracting and

credentialing costs, training costs, and

implementation costs of a billing/electronic

medical records system.

To join either of these projects, please contact

Jeffery Erdman at 217-522-5687 or

[email protected].

mailto:[email protected]

THANK YOU!

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