Medical Billing Implementation: Lessons, Experiences and Challenges - PowerPoint PPT Presentation

Medical Billing Implementation: Lessons, Experiences and Challenges Dr. Kimberly Daly, DNP, APRN, FNP-C, Salem State • University Dr. Dianna Jones, DNP, CNP, FNP-C, Regis College • Diana Denning, MPH, MSN, WHNP-BC, RN, Brandeis • University

Insurance Claims Submissions in College Health Background — Traditionally: No 3rd party insurance billing — Common Funding Sources: - Student Health Fees - General University Budget - Limited “Fee for Service”

Insurance Billing in College Health Rationale for Billing - Fiscal downturn / Financial pressures - Expectation of expanding services - Need for additional staff /resources - Trend toward billing insurance for college health - Pressure from administration and senior leadership - Insurance covers many of our services

Insurance Billing in College Health University and Health Center Benefits - Generate significant annual revenue - New additional source of funding - Minimal financial costs to the University (other than minimal staff time demands) - Provides ability to continue on-site immunization program and expanded point of care testing

Insurance Billing in College Health Student and Family Benefits — No co-pays or other out of pocket expenses for students or families; College Fee serves as co- pay — Visits to Health Services count towards family deductibles — Health insurance state mandated for all — More students covered by family insurance-up to age 26

Insurance Billing in College Health Duties and Responsibilities of Health Office - Collect and enter insurance information - Verify insurance eligibility - Collect referrals as needed - Code procedures and visit diagnosis - EMR - Modifiers - Assist in reprocessing denied claims - Maintain provider profiles in CAQH

Insurance Billing in College Health Services Commonly Provided by Insurance Billing Partner - Credentialing of providers - Contract insurance to be “in network” - Develop fee schedules - Claims scrubbing - Claims submission and processing - Claims status monitoring - Follow up denied claims - Reports and Reconciliation: billing, receivables, collections

SSU Health Services Statistics 2017- 2018 FY 2018 Total Total Unique Annual Students visits for Year Health Services Same day/urgent care visits 720 Routine visits 1152 Psychopharmacology consults 93 Reproductive health 877 Vaccination visits 732 Other 51 Visit totals 1678 3625 2016-2017 totals 1649 3654

SSU Billing Expenses vs. Revenue Billing Expense Report FY15 FY16 FY17 FY18 Total Billing Collections 186,887 $197,172.92 $223,023.00 $240,200 Billing Related Expenses 3 rd party Billing Vendor $16,076.92 $15,840.30 $17,308.76 $19,000.00 Vaccinations $38,727.26 $33,955.26 $44,410.53 $46,000.00 EMR $1,580.00 $0.00 $0.00 $0.00 Grad Student Payroll $7,000.00 $7,000.00 $7,000.00 $10,000.00 Family planning products $0.00 $3,324.44 $11,664.57 $15,000.00 Total Billing Related Expenses $68,599.23 $65,877.31 $85,451.72 $95,200.00 Revenue after billing expenses 118,287.77 131,295.61 137,571.28 145,000

Timeline January October June July 2013- November 2010 2012 2013 March 2013 2014 **** RFP for EMR X External consultant X for billing exploration RFP for 3 rd party X billing vendor Credentialing of X X providers Implementation of X billing

Third Party Billing Partners — RFP released June 2013 — Vendor selected: — Fees — $2000 annual administration fee — 7% collected claims

Regis Community Health Services Statistics 2017-2018 FY 2018 Total Annual visits Health Services Same day/urgent care visits 618 Routine visits 358 Psychopharmacology consults 174 Reproductive health 38 Vaccination visits 177 Other 81 Visit totals 1620 2016-2017 totals less psychopharm Total visits 1446 billed

RCHS Billing Expenses vs. Revenue Billing Expense Report FY15 FY16 FY17 FY18 $ 57K $ 84K Total Billing Collections $64K 1,263 1,465 1,442 Total # Visits Billing Related Expenses: EMR/PM – Athena $3,990 $4,480 $6,680 Additional Staff $25,000 $25,000 $25,000 $25,000 Credentialing (annual maintenance fee) $2,700 $3,900 $3,900 Billing/Coding 0 0 0 $4,800 Technology $ 4,000 $ 300 0 Supervising Physicians $ 12,000 $ 9,000 $ 9,000 $ 6,000 Total Billing Related Expenses $47,690 $42,680 $ 35,580 Revenue after billing expenses $9,310 $21,320 $44,580

Process/Timeline for RCHS — Met with Administration – Full support to move forward — Researched EMR/PM – viewed different programs — Recommend: — Integrated system — Compare various systems — Compatible with college systems if possible — Data collection capabilities — Researched Billing company and other options (In-house billing or contract out) — Credentialed healthcare staff (Should be done by outside company or by EMR company)

Process/Timeline for RCHS cont.. — Negotiated contracts — Reviewed fee schedules — Reviewed EMR/PC systems with IT Department for security and technical issues — Implemented process for system set up and technology update (scanners, printers, laptops, etc.) — Trained front office staff and healthcare providers before go live date — Time line for above 4-8 months — 1-2 years completion

Challenges for RCHS — First EMR was not a good fit for our clinic — First credentialing agent which was associated with our EMR company did not finish the process within the first year. We had to switch to a different company — Training was a challenge with the first EMR company — In-house billing – learning curve

Timeline for RCHS May July – August July 2011 - November/ 2011 August 2011 current December 2011 2011- current EMR Exploration X EMR X Implementation Restructuring of X Health Services Credentialing of X providers – Switched to SBSC after first year Implementation of X billing

BRANDEIS Health Services Statistics 2017-2018 FY 2018 July 1,2017-June 30,2018 Total % of Annual visits Charges Paid Health Services Walk in RN visits (99211) 15% 685 E and M 99212-4, 99202-3 44% 3281 Comprehensive Preventive 65% 307 (99385/99395 Vaccination visits (90471, 90472) 66% 1868 6141 Vaccine supply costs 83% Visit Totals-checked in appts 7196

Billing Expenses vs. Revenue Fall 2017 Spring 2018 FY18 TOTALS Billing Expense Report Total Charges $ $465, 112 Total Insurance Revenue $157,619 $ 99,862 $257,481 Billing Related Expenses Claims processing Staff PT $14,000 Clearinghouse $ 1,487 EMR/credentialing/ training ? Vaccine supply costs 90,000 105,487 Total Billing Related Expenses Revenue after associated 151,994 expenses

Brandeis Process 1. Apply for Site NPI number: nnpes.cms.hhs.gov 2. CAQH for all billing cliniciansproview.caqh.org 3. Apply for insurance contracts-SHP #1 PCP vs specialty, HMO vs Indemnity, Fee Schedules 4. Set up/learn systems for tracking claims submissions and payments/charge adjustments/refunds EHR, Clearinghouse, payspan accounts, ins. accounts 5. Train staff on coding, set up institutional reporting/accounting.

Insurance Billing in College Health Questions and Comments? — Salem State University Kimberly Daly, DNP , APRN, FNP-C Associate Director, Counseling and Health services kdaly2@salemstate.edu — Regis College Dianna Jones, DNP , CNP , FNP-BC Associate Dean and Medical Director Dianna.jones@regiscollege.edu — Brandeis Diana Denning, MPH, MSN, WHNP-BC, RN Administrative Director ddenning@brandeis.edu

Resources — Billing and reimbursement toolkit- Reproductive health focused, but easily modified for college health services http://stdtac.org/ — Insurance billing specialist job descriptions/salary info — http://www.all-things-medical-billing.com/insurance-billing- specialist.html — http://www.medicalbillingandcoding.org/salary/ — American Association of Professional Coders https://www.aapc.com/medical-billing/medical- billing.aspx — Exploring the Fundamentals of Medical Billing and Coding. https://revcycleintelligence.com/features/exploring-the-fundamentals-of- medical-billing-and-coding