Is your Billing Department ready for the Ohio Behavioral Health Redesign? Steps you can start using TODAY to bill it right the first time 1
Who am I? Teresa Heim Behavioral Health Billing Solutions, LLC. www.bhbillingsolutions.com EHR/EPM Implementation Project Manager Behavioral Health, Primary Care and FQHC Billing Specialist 25 years in all areas of Accounting 8 years in Behavioral Health Billing 6 years specializing in Implementation Management and Billing support across Ohio 2
Billing Accountability Goals for today s session Is your current billing process accountable? Do you have a method of tracking each and every claim you process? What is your current reimbursement percentage? Eligibility Tracking What is your current process for checking a client s eligibility with Ohio Medicaid and all payers? FREE Information Do you utilize all of the free information provided to you by Ohio Medicaid and other payers? Understanding how to interpret your 277 claims response file is a critical piece of a successful billing process. 3
Why is it important to utilize a tracking system for our billed services and the reimbursements for these services? Ensure your software system is functioning as expected For example, if you use the BBP for billing and EDI file creation, do you know that every claim billed went out in the billing file? Know with certainty that your claims are billing correctly by maintaining a solid reimbursement percentage for all billed claims Easily recognize changes made by your payers by immediately seeing it reflected in your reimbursement dollars 4
Tracking Billed Services and Reimbursement The example below shows what was billed, what date was billed through and the dollar amount by fiscal year. The second section compares the reimbursement to the billed file. The row highlighted in YELLOW is one week, you would want to look closer at. 5
Tracking Billed Services and Reimbursement- Full year graphed example 400,000 350,000 300,000 300,000 350,000 310,000 308,000 250,000 200,000 210,000 225,000 250,000 150,000 100,000 100,000 50,000 0 Medicaid 1st Qtr Medicaid 2nd Qtr Medicaid 3rd Qtr Medicaid 4th Qtr Billed Services Reimbursement Changes in Reimbursment 6
What can we know at a glance from the graph of a full year billed services vs. reimbursement tracking? Why is our reimbursement percentage averaging 70% for the 1 st and 2 nd Qtr.? What happened to decrease our billed services in Qtr.3? What went wrong with our reimbursement percentage? 400,000 350,000 300,000 250,000 200,000 150,000 300,000 210,000 350,000 225,000 250,000 310,000308,000 Qtr.4 represents the impact of identifying and putting corrective billing processes in place. 100,000 50,000 0 100,000 Medicaid 1st Qtr Medicaid 2nd Qtr Medicaid 3rd Qtr Medicaid 4th Qtr Billed Services Reimbursement Changes in Reimbursment 7
How do we achieve an accountable tracking system for billed services? Bill on a regularly scheduled basis and create a simple Billed vs. Paid spreadsheet where billing information is entered Track date billed, compare to information given by the ESR (NextGen file creation report) and actual file contents Keep a billing database where all billed services are kept and ensure it balances to the Billed vs. Paid tracking Enter weekly reimbursements and compare to the billed file it pertains to calculating your reimbursement percentage 8
Checking Client Eligibility How important is correct client information to your agency? 9
Tracking client eligibility The importance of building an effective, time and cost efficient process Examine your current method for checking client eligibility. Do you use RTS? Do you look up clients manually through a clearing house or the MITS portal? If so, how much time do you spend and how frequently do you process? How many times does a client s loss of coverage cause delayed reimbursement? Does it impact timely filing coverage for payers? Do you know the eligibility status of your wait list clients? How do you check the status for clients who have applied for Medicaid? Do you catch when a client s Medicaid is applied retroactively? 10
FACTS Ohio Medicaid offers eligibility checking in Bulk or Batch format at no charge. Response files include eligibility status, Managed Care Program, limitations to eligibility and highlights errors in submission of ID#. Ohio Medicaid allows you to check eligibility with minimal information. For example, Name, date of birth, and social security # is sufficient, in most cases, to return a complete response including eligibility, address on file and other important information. Almost all clearing houses offer this functionality as well. In most cases, there will be a fee and it will need to be enabled but usually it s substantially less than manually checking or the cost related to RTS. 11
Benefits of Checking Member Eligibility Clients in Ohio change plans and eligibility frequently due to a multitude of reasons. Verifying eligibility PRIOR to billing ensures your claim will go to the correct payer the first time. Clearing House 271 Eligibility files return not only eligibility information, they also include annual deductibles and status of met deductibles in real time. It even includes what type of plan and if a referral is needed. The current political state makes us question the impact of potentially losing Medicaid Expansion. Medicaid allows you to go back 3 years (at least) to determine how impactful changes will be to your organization if this changes. In January 2018, Behavioral Health Agencies in Ohio will have to begin contracting and billing MCO plans. Ohio Medicaid returns what plan, if any, each client is connected with to provide guidance in advance of these changes. 12
Challenges in Eligibility checking? Many systems do not offer 270 file creation functionality within their system WITHOUT partnering with companies to implement the entire 270/271 review process ($$$). Ability to understand the information the 271 response file returns. Manually checking eligibility information is time intensive and allows for human error. The information obtained for eligibility needs to 100% accurate at all times. 13
EMS Healthcare Informatics has created a tool, the Power 270 Generator, to assist with the challenges surrounding checking Member eligibility. This new product is a welcome addition to the incredible library of products they currently offer. 14
Who is EMS Healthcare Informatics? EMS is a niche healthcare information technology firm that provides solutions for financial/administrative and clinical electronic transactions, full implementation and support services. EMS has been serving the needs of Healthcare, Business and IT professionals since 1996. EMS recognized the need for healthcare businesses to be able to easily read and interpret the EDI information they receive from payers and created solutions. 15
The Power 270 Generator With assistance from agencies desiring this functionality, EMS created a tool to easily assist with the process of 270 file creation OUTSIDE your current software program. The Power 270 Generator can work directly from any type of simple demographic report with minimal information. For example, to check if a client has Medicaid for a specific time period, all you need is a name, social security # and date of birth. This tool, and the reader that comes with it, can save time, build efficiency and provide valuable information for any organization. 16
Simple to set up and use: The EMS Power Generator can be up and functional at your agency with minimal time involved Below are some of the available set up options for individual or multiple payer submission. 17
When your 271 eligibility response file is returned, you have different ways to view and utilize the information. Select the Read 271 file to see a detailed listing of the information inside the file. As you can see, there are multiple ways within the tool to view the information. Available options are: Find Search for a specific client. Filter Filter by the type of coverage you want to see. Or you can expand all subscribers or benefits. Another option is to use the EMS Power Reader to export the file to excel which I will expand on in the next slide. 18
Below are some examples of information a 271 file can provide when exported to excel: 19
Realistically, that s just a sample of the critical information that is contained in a 271 file. And that s only the Ohio Medicaid side. For insurance clients, the file contains referral information, annual deductible and current status of patient responsibility dollars. Considering the changes that are coming in Ohio through the Redesign, as well as potential changes to overall healthcare, it will be important to be ready to address with any and all information available. 20
What is a 277 Claims Response file? Why is it important to easily understand and react to the information provided for FREE by your payers? 21
The 277 Claims Response file Most payers, including Ohio Medicaid, return a 277 response file which indicates not only whether a claim will be paid but also multiple fields that tell the story of why they were denied. Within a 277 file, you can easily determine if a client s MCD # is incorrect, what is your reimbursement percentage for the sent file going to be and gives two different fields that interpret and tell you why any claim is denied. By understanding and utilizing the 277 response file, you can see immediate improvement in your overall reimbursement by providing better understanding of the denials you receive and allowing you to correct them PRIOR to the payment being processed. 22
Within a 277 file, there are a variety of fields that indicate information on the sent claims. 3 critical fields in a 277 to use every time are: 1. Claim level status description 2. Line level status description 3. Payer claim control number The first two, when used in combination, tell you the status of the claim and if it was denied, why. The third tells you what number to use to provide a corrected claim. With the Redesign implementation July 1 st, we will be seeing a new set of denials that will range from provider type to modifier usage. It will be important to be able to read and understand these errors from day 1. In the next slide, I will demonstrate one of the ways to use this information 23
As you can see below, it is critical to use both the claim and line level information provided for each claim. Errors returned at line level can mean something different if you analyze the returned information. For example, error 88 Entity not eligible, if returned at the line level combined with a claim level status of accepted, it means the MCD info included is incorrect. If it s returned under a claim level status of denied or unknown, when you check eligibility, you will find the member is not eligible for the time period of the claim. Correcting these errors immediately eliminates your reimbursement impact. 24
The final piece in creating an effective billing process is to provide a schedule that utilizes all of the information we send and receive from payers. Below is an example of a to-do list that implements all of the pieces. 25
Over the next few months, most agencies will be interpreting the changes to the Behavioral Health Redesign and determining changes to their current clinical workflow to accommodate it. Preparing your billing department now, by giving them tools to improve their overall efficiency, accuracy and accountability will allow them to provide support to the agency s goal of maintaining financial viability during this turbulent time. Creating accountability, improving your eligibility process, increasing your understanding of denials and putting together a schedule for your billing team to utilize all information available, will be essential to your success. 26
Feel free to reach out with questions. Teresa Heim Behavioral Health Billing Solutions, LLC. Phone: 614-395-0136 Email: trheim87@twc.com 27