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
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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

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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
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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
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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

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Job Description

• CPT and ICD-9 changes
• Evaluation and Management (EM) 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

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Job Description (cont)

• 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

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Question Its just a simple code. What could
go wrong??
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Procedure actually performed
Pt had a Pap smear
Pt was charged for a Pap smear
Procedure codes charged
Pap smear charged also performed
Procedure codes were correctly used
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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
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Companion codes and modifiers that could have
been charged and would increase reimbursement
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 physicians order
wasnt documented
Documentation errors
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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

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Yadkin County Health Department
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Sample Encounter Form
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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

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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

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Demonstration of Needand Target Market (cont)

• 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).

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Demonstration of Needand Target Market (cont)

• 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

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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 County Health Director
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Marketing Strategy

• Word of Mouth
• Email
• Presentations
• State Conferences

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Wilkes County Health Department
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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.

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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.

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Industry Analysis (cont)

• 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.

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Davidson County Health Department
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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

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Competitors and Partners (cont)

• 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

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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

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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

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Competitors and Partners (cont)

• 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
  its prices.

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Surry County Health Department
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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

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Risk and Exit Plan (cont)

• 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

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Timeline
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November 2009May 2010 Conduct 1 to 2 pre-
post-evaluations
December 2009February 2010 Audit results to
counties and formulate strategy
MaySeptember 2010 Contracts, technical
assistance, evaluations and other services would
be added as needed
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Measures of Success
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Financials
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Financials

• I tried to cut and paste but it didnt work, will
  have to continue to work on this part

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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

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Year 5 Contract Fees
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• 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

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Year 5 Contract Fees
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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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