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
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
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 Services *Limited number of patients served *Cuts in programs and services Revenue *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 Training *Improperly trained staff *Consultants
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
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.
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.
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
Financials • 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
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
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)