Strategies for Improving Medicaid Reimbursement and Billing Processes in Primary Care

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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

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SCHD 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

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Documentation 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

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Perspectives 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

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Strategies to Improve Audit Outcomes

• Coder/Coding Initiatives
• Multidisciplinary Collaboration
• Other Initiatives

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Strategies 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

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Strategies Relating to Work Groups/Committees

• Reimbursement Committee
• Billing and Collections Work Group
• Coding/Documentation Work Group
• Task specific work groups

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Reimbursement 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

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Bill 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

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Coding/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

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Task 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

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Miscellaneous 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

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Miscellaneous 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

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Achievements

• 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

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Lessons 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

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Lessons 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