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Addressing Medical Billing Challenges in Public Health PowerPoint PPT Presentation

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Addressing Medical Billing Challenges in Public Health. CPT Code 96372 ICD-9 Code V25.49 HCPCS Code J1055. Northwest Partnership for Public Health. Also called the Northwest Incubator Group of 10 county health departments Innovative projects for the betterment of public health

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Addressing Medical Billing Challenges in Public Health

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AddressingMedical Billing Challenges in Public Health

CPT Code 96372 ICD-9 Code V25.49 HCPCS Code J1055

Northwest Partnership for Public Health

  • Also called the Northwest Incubator

  • Group of 10 county health departments

  • Innovative projects for the betterment of public health

  • Health Directors act as Board

  • Legislative funding for projects

Definition of Plan

Lack of emphasis on revenue generation

Increases in numbers of patients/decreases in funding

Correct coding and medical billing practices a must for Health Departments

Ashe County Health Department

Definition of Plan

  • Medical Billing Consultant available to the LHD to help with:

    • coding issues

    • billing problems

    • evaluations

    • consultations

    • training

  • Health Department buy-in through Health Director, nursing supervisors, administrative support staff and providers

Alleghany County Health Department

Definition of Plan

  • Four counties will be initially piloted during Year 1:

    • Davidson

    • Surry

    • Wilkes

    • Yadkin

  • Initial funding through the Incubator Collaboratives, then fee-for-service structure

Job Description

  • CPT and ICD-9 changes

  • Evaluation and Management (E&M) code training

  • Primary Care code Training

  • Family Planning code training

  • Immunization code training

  • Diabetes Management Self Training (DMST) and Medical Nutrition Training (MNT) code training

Job Description (con’t)

  • Credentialing with Insurance Companies

  • Be available for coding questions and site visits

  • Assistance with financial policies and procedures

  • Assistance revising encounters

  • Assistance with fee schedule

Question: It’s just a simple code. What could go wrong??

Procedure actually performed

Pt had a Pap smear

Pt was charged for a Pap smear

Procedure codes charged

Procedure codes were correctly used

Pap smear charged & also performed

Pap smear was done but not charged for

Missed charges

Additional codes that could have been charged including codes missing from the encounter form

A Pap smear was done but it was not on the encounter form and the provider did not write it in

Companion codes and modifiers that could have been charged and would increasereimbursement

A Pap smear was done & sent to an outside lab but the additional specimen handling code was not charged

A Pap Smear was done but the physician’s order wasn’t documented

Documentation errors

Operations and Management

  • Fiscal agent is Appalachian District Health Department

  • Incubator Director will recruit, hire and supervise

  • Position will be 1 FTE, housed in Wilkes

  • On-the-job training in Public Health

  • Office of State Personnel classification as Medical Records Assistant V

Yadkin County Health Department

Sample Encounter Form

Demonstration of Needand Target Market

  • Recent audits of 9 northwest North Carolina counties showed:

    • Average of 6 invalid/incorrect CPT (Current Procedural Terminology) codes per county

    • Average of 4 misused codes per county

    • In one county alone, 46 procedures were performed but not charged/billed

    • Lack of audit tools/no universal system for auditing

Demonstration of Needand Target Market


*Limited number of patients served

*Cuts in programs and services


*Decreased monies from Federal, State and Local Agencies.

*Increase Medicaid, third party insurance and private dollars

*Outdated CPT Codes and/or Encounter Forms

*Pay-back of Medicaid/Insurance dollars


*Improperly trained staff


Demonstration of Needand Target Market (con’t)

“Fees shall be based upon a plan

Recommended by the local Health

Director and approved by the local

Board of Health and the appropriate

County Board or Boards of

Commissioners” (130A-39g).

Demonstration of Needand Target Market (con’t)

  • Four primary reasons that correct coding should be a priority for local public health:

    • Incorrect coding is illegal

    • Incorrect coding is unethical

    • Incorrect coding is inadvisable

    • Correct coding and billing will increase revenue

Market Strategy

  • This business plan will be the services of a medical billing consultant.

  • It will be offered to public health departments.

  • Health Directors, as the gate keepers to local public health, will be targeted first and foremost.

Mike Reavis, Yadkin CountyHealthDirector

Marketing Strategy

  • Word of Mouth

  • Email

  • Presentations

  • State Conferences

Wilkes County Health Department

Industry Analysis

The healthcare industry in the US:

$2 trillion industry

Third party insurers pay out $700 billion

Medicare and Medicaid make annual payments of $1 trillion

Annual revenue of $1.5 trillion for care providers

Information provided by First Research, a sales consulting firm.

Thus, medical coding may be said to be the biggest success factor for any medical office. Doing it correctly can mean the stability of your business. Doing it incorrectly could mean the downfall of your practice.

Industry Analysis

Hundreds of millions of dollars are lost annually due to medical billing errors.

The national trend for fixing these issues consists of:

Having a coding/billing specialist in house that stays up to date with current changes in Medicare, Medicaid and third party billing requirements.

Larger corporations hire a regional coder that is responsible for training and billing compliance for more than one office.

Outsourcing to a medical billing and coding company that are often located offshore.

Industry Analysis (con’t)

Currently there are 3 Health Departments close to the Northwest that have “coders”: Cabarrus, Guilford and Mecklenburg

Otherwise, NC health departments use state consultants. Each consultant has anywhere from twenty to twenty-five counties and are responsible for:

Accreditation Policy and Procedures

Quality Improvement

CPT coding audits and training

Support in improving efficiencies

Generalized nursing consultations

Clinical experts for the new HIS system

They are extremely valuable resource. However, they have limited time to help with individual health departments.

Not as able to help with third party billing and insurance credentialing.

Davidson County Health Department

Competitors and Partners

Are diverse and cross over county and state lines and even into the private sector

Partners take the form of local, regional and state level personnel, primarily in public service agencies

Health Directors, health department staff, Boards of Health and County Commissioners form the backbone of our support

Their support helps:

The medical billing consultant provide valuable coding training;

Health departments will provide public health training

Our of state partners who are a valuable asset to the LHD will be the Nurse and Administrative Consultants

Competitors and Partners (con’t)

The medical billing consultant will share the burden for coding questions

Our partners would be interested in participating in this plan because:

We offer a trained and knowledgeable professional

Work loads are decreased

Potential payback situations are decreased

Creates less dependency on grant monies

Competitors and Partners

  • Numerous competitors in our business:

    • Web-based training

    • Insurance companies

    • Other consulting firms

    • CPT coders

  • Using only the “Goggle” search engine for organizations in NC:

    • 1,170,00 hits for Public Health Medical Billing Consultant

    • 73,700 hits for Public Health Medical Coder Consultant

    • 1,180,000 hits for Public Health Medical Coder

Competitors and Partners

Numerous competitors in our business:

Web-based training

Insurance companies

Other consulting firms

CPT coders

Using only the “Goggle” search engine for organizations in NC:

1,170,00 hits for Public Health Medical Billing Consultant

73,700 hits for Public Health Medical Coder Consultant

1,180,000 hits for Public Health Medical Coder

Competitors and Partners (con’t)

Five Organizations offering services similar to project:

TCN, The Coding Network in Beverly Hills, CA

Medical Coding Services, LLC in Pendleton, IN

Healthcare Business Consultants in Asheville, NC

Healthcare Management & Consulting in Bay Shore, NY

Health Care Economics in Indianapolis, IN

Of these five organizations, Healthcare Business Consultants offers consulting advice but it does not have public health expertise nor does it list it’s prices.

Surry County Health Department

Risk and Exit Plan

  • Few risks exist due to funding already secured for two years

  • Health department buy-in may be difficult

  • A potential risk is a State buy-out of the project or if OSP created a new position for LHDs. If this occurs:

    • NW Partnership release control and financial obligation to state

    • A challenge would be dividing revenue (if any) amongst participating counties

    • Consultant would be reassigned or lose position

Risk and Exit Plan (con’t)

  • If there were an unintentional exit:

    • Medical billing project would not continue with lack of structure

    • If in the early stages, the costs would be minimal

    • The in-kind space would be reallocated

    • Computer and technical equipment transferred back to NW Partnership

    • All exit costs would be on the Partnership

  • One strategy for addressing this possibility:

    • Restructure and the consultant be own private and fiscal agent

    • This would still be a challenge due to lack of county money or a governing board


Pre-March 2009

Make initial contacts; NWPPH will vote to approve business plan

March 2009—July 2009

Collect information, write job description

Obtain approval of job description

Post position

Conduct interview; make offer to qualified candidate

Initiate hiring process and public health orientation

July—November 2009

Audits of pilot counties

November 2009—May 2010

Conduct 1 to 2 pre- & post-evaluations

December 2009—February 2010

Audit results to counties and formulate strategy

May—September 2010

Contracts, technical assistance, evaluations and other services would be added as needed

Measures of Success



  • I tried to cut and paste but it didn’t work, will have to continue to work on this part

Contract Fees Years 1 - 4

  • Year 1:No Fees (Pilot Process)

  • Year 2:Base rate of $1,500 for 5 counties

  • Year 3:Base rate of $2,000 for 6 counties

  • Year 4:Base rate of $3,000 for 7 counties

Year 5 Contract Fees

Each county pays a base of $4,000 each x 7 counties = $28,000

$51,000 - $28,000 = $23,000

(Projected Operating Expenses) - (Base Rate) = (Amount needed)

Medicaid Revenues:

Surry County =$3,394,072 Northwest Counties =$7,683,968

$3,394,072 / $7,683,968 = 44%

44% x $23,000 = $10,120

Surry County pays: $4,000 + $10,120 = $14,120

Year 5 Contract Fees

Front Row (L-R): Jan White (Surry), Trish Belton (Yadkin), Candice DuVernois (NWPPH)

Back Row (L-R): Inge Leonard (Davidson), Samantha Ange (Surry), Debbie Widener (NWPPH)

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