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

• 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

Medical Billing Implementation: Lessons, Experiences and Challenges

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 Unique Students for Year Total Annual visits 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 3rd 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 2010 October 2012 June 2013 July 2013- March 2014 **** November 2013 RFP for EMR X External consultant for billing exploration X RFP for 3rd party billing vendor X Credentialing of providers X X Implementation of billing X

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 billed 1446

RCHS Billing Expenses vs. Revenue

Billing Expense Report FY15 FY16 FY17 FY18 Total Billing Collections $57K $64K $84K Total # Visits 1,263 1,465 1,442 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 $4,800 Technology $4,000 $300 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 2011 July – August 2011 August 2011 July 2011 - current November/ December 2011- current EMR Exploration X EMR Implementation X Restructuring of Health Services X Credentialing of providers – Switched to SBSC after first year X Implementation of billing X

BRANDEIS Health Services Statistics

2017-2018

FY 2018 July 1,2017-June 30,2018 % of Charges Paid Total Annual visits Health Services Walk in RN visits (99211)

15% 685

E and M 99212-4, 99202-3

44% 3281

Comprehensive Preventive (99385/99395

65% 307

Vaccination visits (90471, 90472)

66% 1868 6141

Vaccine supply costs

83%

Visit Totals-checked in appts

7196

Billing Expenses vs. Revenue

Billing Expense Report

Fall 2017 Spring 2018 FY18 TOTALS

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

Total Billing Related Expenses

105,487

Revenue after associated expenses

151,994

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