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By Myles Riner
CEP America, an emergency physician partnership that staffs 72 emergency departments across the country (including 62 in California), led a pilot project to address dual-eligible claims. The pilot demonstrates a financial benefit to providers and Medi-Cal when providers processed the recoupment claims.
This is a sample article from HFMA's subscription newsletter, Revenue Cycle Strategist, which helps finance leaders improve their bottom line and maintain regulatory compliance.Learn more and subscribe to Revenue Cycle Strategist.
CEP America learned about Medi-Cal's dual-eligible recoupment program when the DHCS vendor incorrectly billed a patient for services he did not receive, and the patient complained to CEP America. The organization's investigation identified the following concerns with the DHCS program:
For those reasons, CEP America approached DHCS about implementing a pilot project to test whether the provider's billing service could more effectively recoup payments from the commercial insurance. The project began in August 2009 when Medi-Cal turned over 3,369 claims for services provided by CEP physicians for processing by CEP's billing service, MedAmerica Billing Services, Inc. (MBSI). At that time, DHCS estimated that it was due $248,097.03 in rebates for prior Medi-Cal payments on these claims.
On CEP America's behalf, MBSI designed a process that started with manually keying in data because claims were delivered in hard copy. All claims had already been checked against Medi-Cal Online Eligibility Request (MOLER) prior to the initial submission to Medi-Cal.
When CEP America received the refund request letters, this was the first indication that patients may have had dual-insurance coverage. MBSI then cross-checked eligibility with commercial insurance carriers' online systems to confirm accuracy and coverage on the date of service. One additional FTE was required to manage the pilot program, and this position has been made permanent to manage ongoing retroactive refund requests.
MBSI then submitted claims to the commercial insurer when appropriate, and provided the vendor with documentation of the results of the claims adjudication process. Recent legislation extended the timely filing limits for submission of these claims to the commercial insurer, and the DHCS has extended the time allowed for the provider to adjudicate these claims to 120 days before refund retractions are made.
The pilot project was completed in July 2010. Of the claims identified by the DHCS vendor, 66 percent did not warrant recoupment by the Medi-Cal program. Most of these incorrectly identified claims were either not covered by the commercial carrier on the date of service or covered appropriately by Medi-Cal as the secondary payer.
CEP America identified 1,158 claims for which the patient was covered by a commercial plan on the date of service and rebates to the Medi-Cal program were appropriate. As a result, $82,761 was rebated (through retractions) to Medi-Cal (see the exhibit). According to DHCS, this amount significantly exceeded what the vendor had previously been able to collect from a similar number of claims.
CEP America collected $211,315.96 for providers from commercial carriers, for a net gain of $128,555, after rebates to Medi-Cal (i.e., $211,315.96 - $82,761).
Tracking dual-insurance coverage for patients covered by both Medicaid and private insurance resulted in a net gain of $128,555 in revenue for providers in California.
View the exhibit.
This pilot project brought the following benefits to both providers and the DHCS:
These results show that providers can work with state Medicaid agencies as partners to reduce unnecessary Medicaid expenditures. This is a win-win situation, because providers are also able to recover higher reimbursements from commercial insurers than they had from the Medicaid program.
Thanks to the program's success, DHCS will be enabling other physician groups to participate in this program, and has already rolled it out to some hospitals, as well. The result is that other hospitals have experienced similar revenue benefits, which has also improved the Medi-Cal bottom line significantly.
I encourage hospitals to consider screening all patients for commercial insurance coverage at the time of service, even if Medicaid is listed as the primary insurer, to avoid retroactive refund requests. Additionally, all providers should investigate how their state Medicaid program recoups Medicaid payments on claims where the patient has simultaneous commercial coverage to ensure they are not losing out on revenue they could be collecting from commercial insurers.
Currently, the terms of the provider-DHCS agreement include an automatic retraction of refunds from the provider for claims not processed within 120 working days, which CEP America found was necessary as it often takes insurance plans months to respond to these claims. Given the demonstrated financial benefit to providers from participating in this program, I strongly believe there is sufficient incentive for providers to adopt this process without the DHCS requiring automatic retraction of refunds.
Myles Riner, MD, is a partner emeritus, CEP America, Emeryville, Calif. (firstname.lastname@example.org).
Publication Date: Tuesday, March 01, 2011
A leader from McKesson discusses how healthcare reform is forcing hospitals and health systems to take a different approach to capacity management and patient flow.
Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
Emad Rizk, MD, president and CEO of Accretive Health, discusses the uncertainty facing hospitals and the transitions affecting revenue cycle management.
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
Jim Bohnsack, vice president, solution & corporate development for Conifer Health Solutions, explains how the company helps healthcare providers leverage data to deliver better outcomes while optimizing reimbursement for all payment arrangements.
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
Steve Scibetta, senior director of channel sales for Ontario Systems' healthcare product line, shares insights into effectively managing receivables.
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Elena White, vice president of risk, quality, and network solutions for Optum, discusses how healthcare providers can leverage data and technology as they enable risk in their organization.
Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.
Somnia President and CEO Marc Koch, MD, MBA, explains how hospitals can drive transformative change in the perioperative experience for outstanding clinical and financial outcomes.
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
PMMC President Roger L. Shaul discusses the effects of healthcare reform on revenue cycle management and how PMMC's products help clients adapt to a changing financial environment.
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
Greg Burgess, Founder and Chief Product Officer at Burgess Group shares insights and opportunities for payment integrity in the rapidly changing healthcare IT landscape.
Read how Gwinnett Medical Center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process.
Read how Orlando Health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce A/R days.
To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.
Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.
Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.
Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
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