Maximizing Medicaid Billing Efficiency in Healthcare Organizations

1. Business Practices for the Future Learning Collaborative Fee-for-Service, Cohort II This Learning Collaborative was developed for the Substance Abuse and Mental Health Services Administration (SAMHSA) by the University of Wisconsin through JBS International, Inc., under contract numbers HHSS283200700003I/HHSS28300002T, with SAMHSA, U.S. Department of Health and Human Services (HHS).  “The contents of this presentation do not necessarily reflect the views or policies of SAMHSA, or DHHS.”     Kim Plavsic served as the Government Project Officer.

2. NIATx Business Practices (Title) Name(s) of presenter(s) Organizational Affiliation Somerset Treatment Services

3. PROJECT AIM The overall project AIM was to Reduce Medicaid Denials by 10% by March 31, 2012 This AIM was selected in an effort to prepare for upcoming changes in the state funding system and the anticipated increase in Medicaid clients to be admitted to treatment

4. Change Project • Change Project #1 • ENSURE PREQUALIFICATION OF MEDICAID ELIGIBILITY TO PREVENT DENIALS (OR REFER CLIENTS TO OTHER FUNDING SOURCES • DEVELOPED CENTRALIZED MEDICAID VERIFICATION TO ENSURE ACCURACY • DEVELOPED FLOWCHART OF MEDICAID BILLING STEPS • Change Project #2 • IDENTIFY TOP 3 REASONS FOR MEDICAID DENIALS & REBILL • INCREASED REVIEW OF DENIALS BY CLINICAL AND ADMINISTRATIVE STAFF • BETTER DEFINED FOLLOW-UP ON DENIALS AND LIAISON BETWEEN CLINICAL AND ADMINISTRATIVE PERSONNEL WORKING ON THESE ISSUES

5. RESULTS RESULTS-CHANGE PROJECT #1: • RESULTS: 100% OF CLIENTS WITH MEDICAID WERE PREQUALIFIED • PRIOR TO ENTERING TREATMENT ( ALL OTHER CLIENTS WERE ADMITTED UNDER OTHER FUNDING SOURCES)-PROCESS ADOPTED • RESULTS-CHANGE PROJECT #2: • IDENTIFIED TOP 3 REASONS FOR DENIALS: • LACK OF PREQUALIFICATION FOR MEDICAID • CHANGES FROM MOLINA-PROBLEM WITH LINKAGE TO NPI TO SAI AND MEDICAID PROVIDERS 3’S • NEW REQUIREMENT FOR TAXONOMY & ZIPCODES NOT CLEAR/CONSISTENT • AFTER MANY HOURS OF RESEARCHING, STS DID RESUBMIT BILLING & REDUCED DENIALS BY 60%

6. 2011 vs. 2012 Medicaid Billing-Payments-Denials Jan Feb Mar Billed 1287 1275 1432 Paid 1170 1043 1255 Denied 117 232 177 Jan Feb Mar Billed 1567 1391 1491 Paid 1056 0 1031 Denied 512 1391 460

7. Response to Results of Change Project Change Project #1 Process of centralized prequalification for Medicaid was adopted Change Project #2 Process of thorough review of Medicaid denials was adopted Sustainability: All processes developed to prevent billing denials were retained and the Change Project Team will continue to meet on a monthly basis to review all billing functions from clinical and administrative perspectives to trouble shoot and prevent further billing issues

8. Impact/Lessons Learned COORDINATION BETWEEN CLINICAL AND ADMINISTRATIVE STAFF IS KEY CENTRALIZATION OF KEY BILLING FUNCTIONS IS ESSENTIAL ENGAGEMENT AND TRAINING FOR ALL STAFF AND BOARD MEMBERS IS IMPORTANT AGENCY REVENUE CAN BE INCREASED BY FOCUSING UPON ISSUES IN THE BILLING PROCESS BRINGING DIFFERENT DISCIPLINES TOGETHER (e.g, BILLING AND CLINCAL) CAN ENHANCE THE PROBLEM-SOLVING PROCESS COLLABORATION BETWEEN DIFFERENT DISCIPLINES CAN BUILD BUY-IN TOWARD FUTURE BUSINESS GOALS