Health Home Billing Questions and Answers

1
Health Home Billing Questions and Answers
An overview of billing, potential issues, and
best practices
Health Home Biweekly Implementation Webinar,
Session 15 April 24, 2013
2
Who can bill for HH services?

• For the first two years of each phase, converting
  OMH TCM, COBRA, and MATS programs bill Medicaid
  directly for ALL Health Home services they
  provide.
• Converting programs bill for both their existing
  members AND all new Health Home members.
• Converting programs can bill a limited number of
  claims per month under their legacy rate codes
  (1800 series) and bill the remaining claims under
  the 1386/1387 rate codes.

3
Who can bill for services?

• Health Homes are responsible for billing Medicaid
  for fee for service members that are NOT
  receiving services from a converting provider
• Managed Care Plans are responsible for billing
  Medicaid for their plan members that are NOT
  receiving services from a converting provider.
• After the first two years of each phase, Health
  Homes and Managed Care Plans will bill directly
  for ALL members regardless of the entity
  providing Health Home services.

4
Billing for Health Home Services

• The entity responsible for billing must submit a
  claim to eMedNY in addition to submitting member
  information to the HHTS Portal.
• 1386/1387 claim payments are calculated by
  multiplying a members acuity score by the
  appropriate base rate.
• If a member does not have an acuity score on
  file, the claim will pend until the average
  statewide acuity score can be loaded at which
  time the claim will pay.
• Legacy rates (1800 series) are loaded with an
  average rate based on past billing. Acuity scores
  do not factor into payment of legacy claims.

5
Acuity Scores

• Acuity is a weighted average based on total
  Medicaid fee-for-service and managed care
  encounter costs associated with the Clinical Risk
  Groups (CRG).
• Acuity calculations are not real time, so a
  patients acuity score may not always reflect the
  members current health status.
• Updated acuity scores will eventually be released
  quarterly.
• The statewide acuity score is the average acuity
  score of the high risk high need HH eligible
  members.

6
What is Duplicate Billing?

• Duplicate billing is when two entities bill for
  Health Home services for the same member in the
  same month.
• The system will only allow for the billing of one
  service per member per month
• If two entities attempt to bill for Health Home
  services for the same member during the same
  month, the first claim submitted will be accepted
  by the system and the second claim will be denied.

7
Why Does Duplicate Billing Occur?

• Confusion over which entity is responsible for
  billing Medicaid for HH services.
• Correct member enrollment information is not
  submitted to the HHTS Portal in a timely manner.
• Health Home partners have not yet completed DEAA
  subcontractor packets enabling them to share
  patient information.

8
Determining Entity Responsible for Health Home
Billing
Yes
No
Yes
No
Yes
No
NOTE Converting programs (OMH TCM, MATS, and
COBRA) bill directly for members that were
enrolled in their programs prior to Health Home
conversion AND new members assigned to their
programs by Health Homes.
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What can be done to avoid duplicate billing?

• Complete agreements ASAP to allow member
  information exchange.
• Submit correct records to the tracking system in
  a timely manner.
• Look up a members HH enrollment status using the
  Portal member search function before providing
  services.
• CMAs must contact the members MCP or a HH for
  FFS members to determine if a referred member is
  already enrolled.

10
What can be done to avoid duplicate billing?

• DOH is implementing enhancements to the HHTS
  Portal Member Lookup Function
• Making HH enrollment history available to all
  Portal users
• New flag indicating if a member has recently
  received a converting service.
• HH/MCP should be available to look up members HH
  enrollment in the portal for downstream providers
  and should share all info downloaded from the
  portal with CMAs they are working with.

11
Health Home Communication

• All regional Health Home partners (Managed Care
  Plans, Health Homes, and Care Management
  Agencies) should establish communication to
  better facilitate Health Home services.
• Please see the following power points regarding
  sharing patient information.
• http//www.health.ny.gov/health_care/medicaid/prog
  ram/medicaid_health_homes/docs/2013-03-27_hh_medic
  aid_webinar_session13.ppt
• http//www.health.ny.gov/health_care/medicaid/prog
  ram/medicaid_health_homes/docs/2013-04-10_hh_cmart
  _weekly_support_call_session14.ppt