Title: Strategies for Improving Medicaid Reimbursement and Billing Processes in Primary Care
1 Strategies for Improving Medicaid Reimbursement
and Billing Processes in Primary Care
- Barbara B. Laidlaw, M.P.H., R.N.
- Senior Community Health Nursing Director
- Director, Clinical Community Health Services
- Sarasota County Health Department
2SCHD Experience
- 10 years ago, SCHD was required to repay
approximately 125,000 in Medicaid revenue as a
result of documentation deficiencies identified
during an AHCA audit of patient care records - Hospital and clinic based service records were
reviewed
3Documentation Deficiencies Examples
- Missing provider signatures and titles
- Incongruence between date of service documented
in the clinical record and date on billing record - Missing required components for physical
exams/episodic care visits
4Perspectives Based on Personal Experiences
- Early training and involvement in the Medicaid
cost-based reimbursement processes - Establishing a collaborative, ongoing dialogue
with ancillary and fiscal partners - Cultivating an attitude of entrepreneurship
5Strategies to Improve Audit Outcomes
- Coder/Coding Initiatives
- Multidisciplinary Collaboration
- Other Initiatives
6Strategies Relating to Coders/Medical Coding
Processes
- Investing in credentialed coders
- Ongoing education/training
- Expanding coder duties to include chart auditing
- Providing necessary tools
- Remote access to hospital based service records
- Tracking coder productivity
7Strategies Relating to Work Groups/Committees
- Reimbursement Committee
- Billing and Collections Work Group
- Coding/Documentation Work Group
- Task specific work groups
8Reimbursement Committee
- Purpose Identify opportunities to maximize
revenue, review agency wide and individual unit
issues surrounding fee assessment and collection
processes - Multidisciplinary team that includes staff at all
levels including participation at the executive
level to support policy and decision making. - Representation Coders, Fiscal, cashiers,
clinical services, administration
9Bill Collections Work Group
- Purpose process mapping of services/superbills,
increase efficiency/accuracy of billing
procedures, identifying missed revenue
opportunities - Representation Fiscal, clinical services,
coders, IT
10Coding/Documentation Work Group
- Purpose Development of clinical forms that
facilitate provider documentation of services
consistent with third party payer requirements
and superbills that include common ICD-9 and CPT
codes - Representation coders and clinical services
11Task specific ad hoc work groups
- Purpose Development of payment procedure for
special populations (i.e. pregnant women only
eligible for PEPW, women here on valid visas) - Represenation task specific
12Miscellaneous Strategies
- Development of an agency compliance plan for
coding and billing processes, et al. - Supporting and maintaining in house Medicaid
eligibility services and case management - Provider training and education in medical coding
procedures - Timely billing and prompt follow-up of claim
denials
13Miscellaneous Strategies (continued)
- Expert evaluation/analysis of clinical, coding
and fiscal procedures (Lil Perry, DOH) - Tracking/monitoring expense/revenue reports
- Negotiation of simplified contractual agreements
with third party payer sources
14Achievements
- Successfully process mapped superbill progression
and removed redundancy (duplicate handling) - Developed a seamless process to minimize risk of
missed billing opportunities - Established a Medicaid eligibility office inside
our Womens Health unit to interact with and
increase the number of women who become eligible
for Medicaid during pregnancy
15Lessons Learned
- Importance of an interdisciplinary
approach/involving all stakeholders - Value of investing in credentialed coders
- Assuring accuracy
- Reducing Liability exposure (repayment)
- Maximizing reimbursement
- Value of continuous education/training
- Value of entrepreneurship/expanding ones
perspective beyond the clinical realm
16Lessons Learned (continued)
- Value of continuous evaluation and improvement of
processes - Early identification of problems
- Opportunity for prompt resolution
- Value of administrative support
- Empowering stakeholders to explore and implement
new ideas