California
Public Health Billing Project
Denise Smith, PHN, MPA
Director of Disease Control
Kern County Public Health Services
Director, California Public Health Billing Project
TODAY
Services are free at the
Health Department!
Planning Grants
NYC
Duane Kilgus; CDC Stakeholder Meeting, February 1, 2012
CA Insurance Landscape
18.5%
Insurance Coverage
52.1%
8.8%
6.1%
14.5%
Private Insurance
Medi-Cal
Medicare
Other Coverage
No coverage
State Capacity Analysis
Clinical Services:
• 10% provide immunizations only
• 7% provide immunizations and one other
service (i.e., family planning, TB clinic, STD
services, HIV services, prenatal services)
• 25% provide immunizations and two other
services
• 38% provide immunizations and three or more
other services
• 8% provide primary care services including
immunizations.
State Capacity Analysis
Billing Services
• 11% bill insurance, Medi-Cal, and Medicare
• 31% complete Medicare roster billing only (flu
•
•
•
•
vaccine)
18% bill Medi-Cal and complete Medicare
roster billing
7% bill Medi-Cal only.
20% complete no billing and provide services
for free or a nominal administration fee.
13% provide no clinic services at all.
Kern County Landscape
2008-2009
VFC Eligible
317
Potential revenue if
insurance had been
billed
23%
77%

2009 - 2010
VFC Eligible
317
43%
57%

2008/09: $210,640
2009/10: $228,931
Kern’s Process
 Updated Fee Schedule
 Initiated Private Insurance Contracts
 Provider Credentialing
 Enhanced Insurance verification
 Improved Coding & Medical documentation
 Developed better Clinic Flow and Staff
placement
Fee Schedules
 Evaluate costs of doing
service

National Fee Analyzer;
Medi-Cal and Medicare
rates
 Sliding Fee Scales
Kern Contracts
Aetna
Anthem Blue Cross
Blue Shield
Humana
Medicare
Managed Care
System
SISC
Tri-West
United Health
Care
• Initial Stages
• Approved 5/1/2012
• Awaiting contract completion
• Executed 4/25/2012
• Actively Billing
• Submitted to BOS 4/17/12
• Rejected; trying for ancillary contract
• Approved March 2012 retroactive to
6/2011; EDI approved 8/12
• Contracted 8/10
• Actively billing
• Approved 5/1/2012
• Awaiting final signatures
• Clinic Contract
• Lab Contract Executed 9/1/12
• Submitted 1/2012
• Rejected for lack of hospital privileges
Billable
Contract
Credentialing
• CAQH Universal Provider
Data Source
• NPI Numbers
Consent and Disclosure
Insurance Verifier
• Contact the carrier prior to
services to verify benefits
• Accurately record
authorization
• Relay coverage benefits to
patient
Why Documenting is Crucial
• If it isn’t documented,
it didn’t happen!
• Errors occur when
documenting is
inconsistent,
incomplete or illegible.
Patient with Insurance
Front Office
Provider
Cashier
Biller
Sign consents
and collect
insurance
cards
Verify Insurance
Coverage with
payer
Provide services
Collect fees, copays
Bill insurance
Monitor
receivables, follow
up on any denials
Explain benefits
to patient
Record
services:
Coding and
Documentation
Make
Corrections,
resubmit bill
Bill
Paid
Kern County Pilot Project
Tdap Project

Billed for Tdap vaccine for 75
subscribers


$3,375 at $45/vaccine
$1,470 for administration at
$20/vaccine
(contract amount was $10)

Collected $2,989 for vaccine (89%)

Collected $690 for administration fees
(92% of contract amount)
Kern County Results


Total Revenue increased from
$42,961 (7/09 -12/09) to
$491,317 (1/10 – 6/10)
Private Ins. revenue increased
from $6,087 (7/09-12/09) to
between $9,568 and $11,681
for each 6 month period since
1/10.
Clinic Fees (Cash from
patients) increased by over
$40,000 in a 6 month period.
$400,000.00
$300,000.00
Jul-09 to
Dec - 09
Jan - 10 to
Jun -10
$200,000.00
$100,000.00
$0.00
Clinic Cash

$500,000.00
Insurance
Specialist:
$600,000.00
Revenue
 After hiring an Insurance
Barriers
 Contracting with private
insurance carriers
 Staff Resistance
 Changing Fee Schedule
 Shared Tax ID
 Accounts Receivable
Reporting
Kern’s Billing Toolkit
 Several states have
requested copies
 Many places are
using it!
Implementation Grants
Additional Planning Grants
Duane Kilgus; CDC Stakeholder Meeting, February 1, 2012
NYC
Houston
Planning
Implementation
Plans for Implementation
“Stay with me
now, people,
because in
step C, things
get a bit
delicate.”
Implementation Process





Seven CA counties
selected to
participate
On-site training
with each site
Post-training
consultation
Billing workgroup
Webinar training
Humboldt
San Joaquin
Mendocino
Contra Costa
Long Beach
Madera
Tulare
San Joaquin County
 Paper billing


Medi-Cal, County
Plan, Managed Care
Lots of denials; no
one to follow up
 Problematic clinic
flow resulting in
many patients not
paying
Madera County
 No billing, but ready to
begin
 Fee schedule in process,
but not approved
 No EMR, but shopping
 Very motivated
City of Long Beach
 Strong, established
billing system, but lots of
denials
 Fee schedule has built
in renewal process and
cost of living
component, but no
sliding scale
 Motivated to improve
and expand
Humboldt County
 Recently upgraded EMR
 Very billing savvy
 Eager to begin billing
3rd party
 Well trained staff,
ready to move forward
Contra Costa County
 Proactive, looking for
training prior to EMR
implementation
 Currently billing DOT
only
 Much room for expansion
 Eager to learn billing for
Lab and IZ services
Tulare County
 Currently billing for Lab
and FQHC; not yet billing
for IZ or TB clinics
 Eager to begin billing for
mobile clinics
 Good billing system in
place and prepared to
expand
The Trainers
 Athina Kinsley,
Health Insurance
Specialist
 Timi Granados,
Billing Project
Coordinator
Training Modules
 Module #1: Preparing Your Site for





Billing
Module #2: Navigating Contracts and
Enrollments
Module #3: Billing & Coding – Medi-Cal
Module #4: Billing & Coding - Medicare
Module #5: Billing & Coding - Private Insurance
Module #6: Coding & Documenting for Providers
Training Goals






Modify training to meet individual needs
Review Charts to identify consistent errors
Practice dialogues to help employees gain
confidence in speaking with patients and health
plans
Work hands on with billing team to resolve denials
Follow-up visits to reinforce training and monitor
results
Advanced training when needed
Training Schedule
 San Joaquin
May 14 – 18
 Madera
June 18 -22
 Long Beach
July 9 – 13
 Humboldt
August 7 – 10
 Tulare
Sept. 18 -21
 Contra Costa Oct 23 - 25
Billing Workgroup
 Held Monthly
 Monthly Topics help establish
and improve LHJ billing
practices
 Share experiences and ideas
to create an in-state network
of help
CAIR Modifications
 California Immunization
Registry



Enhancements launched
July 1, 2012
System now allows users to
track 317 vs. VFC usage
Looking at Medi-Cal billing
within Registry
Challenges
 Difficult to get management support in some
areas
 Lack of project liaison at some sites
disrupted continuity and movement of
information to other workers
 Uniqueness of each county made
comparisons difficult at times
Questions?