1 / 22

Medi-Cal Paid Claims Reports Huh???

Medi-Cal Paid Claims Reports Huh???. Joanne Roberts, PHN Perinatal Services Coordinator Los Angeles County November 14, 2013. Objectives. Perinatal Services Coordinators will: Be able to interpret the information on the Medi-Cal Paid Claims Report

daphne
Download Presentation

Medi-Cal Paid Claims Reports Huh???

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Medi-Cal Paid Claims ReportsHuh??? Joanne Roberts, PHN Perinatal Services Coordinator Los Angeles County November 14, 2013

  2. Objectives Perinatal Services Coordinators will: • Be able to interpret the information on the Medi-Cal Paid Claims Report • Understand why the Paid Claims Report is an essential component of quality assurance and monitoring

  3. What Is It? • Report of claims paid by Medi-Cal for a 6-month period: Jan-June and July-Dec • Fee-for-service only • Does not include Medi-Cal Managed Care, FQHC, RHC, IHC

  4. 3 Separate Reports • Delivery Only • Non-Delivery Only • CPSP Only

  5. Non-Delivery & Delivery Only • Non-Delivery: prenatal, postpartum, and global codes • Delivery Only: deliveries (excluding global billing codes) • Use to identify/recruit new CPSP providers

  6. CPSP Report • Health education, nutrition, and psychosocial services • CPSP bonuses: early entry and 10th visit • Monitor CPSP provider activity

  7. What’s in the CPSP Report? • County Name • Provider Type Code • Provider Specialty Code • Provider Legal Name • Provider Address, City, Zip Code

  8. What Does It Tell Me? • Who’s billing CPSP in your county? • Do you recognize all the names? • Non-CPSP providers? • Approved providers missing? • Different address? • Approved providers with unknown sites?

  9. What’s in the CPSP Report? • “Claim Count” • Number of services • “Total Billed Quantity” • Units of service • Example: • Claim count (# of services) = 50 • Total billed quantity (# units) = 147

  10. Claim Count & Quantity • Compare the numbers • Quantity usually 2-3 times more than Count • When Count = Quantity • Only 1-unit services are billed • Usually means bonuses only • Could be billing error

  11. Now for the Money! • Does the total amount paid fit with the provider type? • Is small solo practice making $200,000 for CPSP only • Is large hospital clinic making only $10,000

  12. Red Flags • Providers reimbursed more than expected • Misunderstanding • Intentional overbilling (fraud) • CPSP done at multiple sites billed from one site (other sites may not be CPSP approved)

  13. Red Flags • Providers reimbursed less than expected • Misunderstanding by provider staff • Biller not billing correctly: “Medi-Cal doesn’t pay.”

  14. Hospitals • Lower than expected reimbursement? • Billing departments and clinic staff don’t communicate • Clinic staff may not mark correct # units • Billers submit as claims “Quantity = 1” for all services, regardless of # of units provided • Hospital computers programmed to discard any claim below a certain amount ($25, $50)

  15. What Do I Do With It? • Review prior to calling/visiting any fee-for-service provider • Ask provider how billing is going? • Compare response to paid claims amount

  16. Example #1 PSC: Hi, I’m calling to schedule your annual CPSP quality assurance review. Office Manager: Oh, we’re not doing CPSP right now. PSC: Really, because the report I’m looking at shows that you billed $187,000 just for CPSP services between January and June of this year. Office Manager: That’s impossible!

  17. Example #2 PSC: Hi, I’m calling to schedule your annual CPSP quality assurance review. How’s everything going? Are you billing for CPSP? Office Manager: Everything’s great! We’re seeing a lot of CPSP patients and the billing is fine. PSC: Are you sure because I have a report that shows you haven’t been reimbursed anything in the last 6 months. Office Manager: (silence)

  18. Let’s Look at the Report Paid Claims Report Jan-Jun 2013 Volunteer needed!

  19. Next Steps • Update the billing codes used in the CPSP, Non-Delivery, and Delivery Only reports • Rename the column labels to be more self-explanatory • Continue relationship between MCAH and Medi-Cal to ensure uninterrupted availability of the Paid Claims Report

  20. Conclusion • Paid claims are invaluable to PSCs • The report’s not that complicated once you know what you’re looking at

  21. Billing Resources • Medi-Cal: www.medi-cal.ca.gov • Provider Manual, Bulletins, Learning Portal, contact Regional Representative • ACS/Xerox (Medi-Cal Fiscal Intermediary) • Telephone Service Center (TSC): 1-800-541-5555 • To leave a message for a Regional Representative, call the TSC then follow the prompts 11, 15, 14

  22. Thank you! Joanne Roberts, PHN (213) 639-6427 jroberts@ph.lacounty.gov

More Related