Claims Processes: A Mirror for Organizational Competence

1. Claims Processes: A Mirror for Organizational Competence Center for Substance Abuse Treatment DSCA Meeting October 21, 2009 Crystal City, Arlington, VA

2. Understanding Claims Processes • Submitting prompt, clean and accurate claims that get paid in full the first time they are submitted is a worthwhile fiscal and organizational goal that communicates your competence • Efficient and effective claims submission allows providers to support services and staff, benefit from utilization and fiscal data, evaluate and accumulate financing, and be accountable

3. Patients, Payers and Purchasers: Expectations • Patients: fair, accurate and prompt billing for covered services by covered, supervised and licensed providers who are accountable and audited/errors are rectified promptly • Payers: prompt, accurate billing according to policy and procedures set out for each customer/purchaser of that payer; eligible providers and organizations are enrolled with payer; billing is for services that are covered, medically necessary, appropriate and complete • Purchasers/Payer Customers: claims are submitted according to procedures and time/benefit limits, medically necessary and appropriate for covered individuals, claims reflect direct covered services provided accurately by approved practitioners

4. Typical Requirements and Considerations for Claims Submission • Provider is enrolled in payer and purchaser’s plan; knows benefit coverage rules, checks patient eligibility and is licensed, certified, eligible, has sufficient administrative and clinical staff to function competently, has signed contract with payer that sets out rates, rules, denial, UM processes, timing of payments, audit requirements, performance reporting, incentives, if any • Provider follows procedures in submitting claims and can do so according to payer and purchaser preference (paper, electronic, fax, mail), also understands appeal and error correction procedures, can track status of services, provider of record and can verify services billed • Providers are expected to request claims policy and procedure manuals, attend trainings if offered, understand differences in coverage and eligibility rules by customer/purchaser (even state by state), able to follow eligibility rules, can check eligibility and understands coverage rules, understands covered and excluded services and provider types, can review and correct errors and denials (tracking), able to audit, demonstrate compliance with performance measurement and management/QM

5. Considerations Continued • Providers must have a functioning contemporary MIS and Web Browser (their own or shared or contracted) that can track individual and batched claims and ascertain status of payment or denials, track payer conformance with payment rules • Can submit claims as specified by payer/purchaser: paper, electronic, EDI/clearinghouse, Internet/Web, scanned or faxed or mailed • Provider understands if he/she/organization is a covered provider under each plan of each payer. EG: NM Medicaid covers state-licensed alcohol and drug counselors but some payers do not allow them to bill • Services and organizations must be eligible, non-experimental, certified/licensed, provided according to coverage rules and limits, co-payments collected, benefits understood by purchaser • Services must be provided within the scope of the provider’s license • Claims must include relevant service or procedure codes, date and type of service, provider type/name/ID, coding conforms to coding manuals and current coding conventions and initiatives • Patient eligibility has been verified at time of service (especially for plans that churn like Medicaid) • Provider records consistent with claims submitted as to extent, nature, provision of service by eligible provider/organization, to eligible recipients

6. Coverage Criteria • Often specified in P and P manual, or Summary or Detailed Plan of Benefits Provided by Payer • Medically necessary and appropriate (need to seek out definition, which can change by customer and payer, also check formulary status for medications • Services include all assessments, testing, therapies, medications, to be completed within specified time frames and within benefit rules • Frequency and place of service conform to medical necessity, documented evidence base • Treatment agency requires patient participation in treatment planning, progress reporting, documentation of family/guardian involvement if appropriate • Provider records available for payer auditors review on request • Services are provided in an eligible setting (example of services in ineligible settings) • Injections/infusions and tests are performed according to national standards, reflect appropriate levels of accuracy • Non-covered, excluded services are understood (e.g. Rolfing, hypnotherapy, biofeedback, V-codes, milieu therapy, strictly educational or vocational services, ECT, services solely for custodial care

7. Prior Authorization, Utilization Management, Outcomes Analysis • May occur before, during or after service billing is submitted or payment is provided • Providers need to ask about these processes, when in the claims process they occur, how to appeal denials and answer questions (information needed to be on hand to talk to UM manager) • Understanding reconsideration and adjustment processes is important to your cash flow, as is correcting errors and insuring that claims have complete and accurate information when they are submitted the first time

8. Reimbursement • Can be per service, per episode, case-based, negotiated fee – or not, batched, capitated, partially capitated • Reimbursement claims must be submitted in/on proper format • Movement towards electronic submission (but not necessarily electronic payment), also use of EDI/clearing houses, enrolled fiscal agents • Providers expected to understand role of usual and customary payments • Providers may be asked to offer prompt pay discount • Providers need to know state’s prompt/clean claim laws (differ by state) • Some practitioners are not eligible to bill directly, nor are supervisors allowed to bill on their behalf • Services must be covered and provided by eligible practitioners in approved locations, frequencies and amounts, duration appropriate • Payments may be reduced if outpatient services are offered in an inpatient environment when they could be provided in a covered outpatient setting

9. Management of Eligibility • Involves ability to check patient/client eligibility prior to providing service – or willing to eat the cost • May need to check “dumb” terminals or Web, accept tape dumps and process updates to benefits and eligibility (part-time, full-time, active, retired, out of state, dependent coverage or not, married or not, etc.) • Need to be able to challenge and correct payer errors (e.g. names, dates, location/setting, type of service, frequency, duration, etc.) • Need to have good access to accurate eligibility in order to do this

10. Provider Credentialing/Network Status • Certain types of providers may not be eligible to bill, even for covered services • Network status for an MCO may be time-consuming, rates negotiated must be accurately reflected by service • Payers expect records, reports, MIS to conform to JCAHO, CARF, NCQA formats and requirements • Primary source verification may be required • Providers must be eligible, contracted and enrolled in order to be paid • Outcome and performance measurement, audits and reports may be required by service, by client, by episode of care or case for network and/or non-contracted providers

11. Fee Schedules and Negotiated Rates • Fee schedules and/or negotiated rates or pay for performance may pertain to specific services • Fee schedules and rates must be accurately reflected, updated as needed • Submitted claims should have been checked for financial and claims/clinical information accuracy and completeness (scrubbing) – can be done by fiscal agent or clearinghouse • Payers may create performance report card, including claims/UM performance, adherence to contracted rates/fee schedule, minimal number of “outliers” or errors

12. Service Tracking/Cash Flow Management • Must have or contract for MIS that can track service provision • Providers need prompt, accurate claims payment in order to have consistent and sufficient cash flow • What stops claims process? Errors, missing information, lack of understanding of eligible services, providers or locations for care or types of services • Must be able to maintain client and transaction security and confidentiality (42 CFR) and still submit claims promptly (releases must be signed promptly) • Must understand own costs compared to reimbursements received • Must be able to do incident reported (e.g. deaths, morbidity, complications of services, procedures, medications • May be wise to use billing services with scrubbers, code updates, prompt submission capabilities, bad debt management, denial tracking and advocacy, clean claims laws’ dispute management, overlooked procedures and codes, reports of final adjudication decisions (with record of adjustments)

13. Do’s and Don’ts of Filing Clean Electronic Claims • Do • Verify, file and keep all transmission reports • Track clearinghouse claims to ensure transmission • Ensure your software embodies clean claims rules • Verify that your software correctly and visibly prints on appropriate claims forms • Call your vendor (if any) to address deficiencies promptly • Track status of appeals or adjustments • Keep track of negotiated rates in master file by payer

14. Example: Optum Behavioral Health Solutions (UBH Online) • Has both public and private sector customers • Accepts EDI and electronic claims • Has function to check eligibility of various services, codes, medications, providers, organizations, level of service, location of service • UM manual is available on line or in print • Covered services and other requirements differ very substantially by purchaser and by time (annual or more frequent updates) • Requires agreement to audit and/or recoupment of funds, as specified by purchasers • Generally pays clean claims from eligible providers in four weeks • Has electronic system functioning 24/7 at 99.7% uptime • Can check status of claims on line via claims inquiry function • Has certain browser requirements • Covers some but not all MAT’s, covers SBIRT if eligible by purchaser

15. Example: AHCA Florida/Medicaid • Providers expected to be under contract with each county • Providers must be Medicaid enrolled • Providers must be licensed (except for recovery services) • Providers must have certified administrative and clinical capacity, appointment times, etc. • Claims must be submitted only for covered providers and services • Claims payment may be extended due to need to deal with Federal and state share of claim • Services provided must have been authorized, eligible • Providers may use Medicaid enrolled billing agents or approved clearinghouses to submit claims to counties (no direct provider billing of Medicaid)

16. Reimbursement for SBI(RT): Examples, Variations • Approved codes through commercial insurance CPT codes, Medicare G Codes and Medicaid HCPCS Codes • Medicaid: H0049 : Alcohol and/or Drug Screening • H0050 : Brief Intervention (no codes for BT or referral services) • CMS G- Codes (Medicare) • GO396: 15-30 minutes for positive screens only) • GO397: more than 30 minutes • CPT Codes (Commercial Health Plans) • 99408: 15-30 minutes • 99409: more than 30 minutes

17. SBI(RT) Code Implementation • Varies by state, county and payer/purchaser • Very specific processes apply for review of all new codes and/or requests to open coverage for existing codes not currently open in systems such as Medicaid (many codes are dormant) • Providers can check state/county websites or provider bulletins or call payers in some states for code approval updates and rules for using codes • Very little utilization reported to date, due to providers not knowing or using codes or states/counties not implementing them • States can approve code implementation but codes still have to be funded in order to be used by providers (legislators may disagree with agencies) • States/counties may report that codes are turned on before they are actually implemented and funded (tend to count those that are in process but processes can take long periods of time if reviews are negative or processes are not followed) • Codes may only be reviewed and approved yearly • Payers may not agree with states regarding turning various codes on; may frustrate state/county directions to do so; may also have lengthy review processes (need to check status) • Many code implementation reviews are affected by “other considerations” including what other codes are being implemented, reviews of science or cost-effectiveness

18. SBI(RT) Code Implementation (Continued) • Processes can be arcane and are often not known to SSA’s • Code implementation and funding may require “champions” on code committees that resemble health plan pharmacy and therapeutics committees – may require evidence base and cost effectiveness data to be submitted, may have several hearings, may be opaque – not transparent • May be debatable whether or not SBI(RT) requires Medicaid state plan changes • In some states that have implemented codes, few or no claims have been submitted (hard for providers to know when the processes are implemented for which services) • New, implemented codes may be listed in fee schedules updates (annual) – time lag • Codes may be subject to subject matter expert review (clinical) as well as economic and other considerations • CMS has set aside Medicaid funds to pay MD’s to conduct SBI but not many states have actually announced that they are reimbursing for the SBI codes • Payment levels for SBI may be modest • Some payers are pushing the use of new codes; some are not

19. The Claims Story • Varies by payer, purchaser, provider types, locations/settings, evidence-base required, certification and licensure, UM requirements • Is necessary and not avoidable to understand • Requires accuracy and good MIS • Is feasible but complicated; requires training of staff • Varies by type of service even within plans of benefits and purchasers • May not yet have been updated for parity conformance • Is essential for your fiscal health and future • Is moving rapidly to at least electronic submission and/or the Web • Can be mastered through persistence and precision • Clean claims can yield positive cash flow, prompt payment • Can be useful to paint a favorable picture of your operations and effectiveness • Are often part of performance management • Can tell a good story – or a bad one

20. Do’s and Don’ts of Filing Clean Electronic Claims Don’t • Use any punctuation or decimals on electronic or other claims • Fold claims (if paper or fax) • Label claims (i.e. second request) • Write out claims by hand • Use lower case letters • Stray outside lines of claim boxes • Forget to check to see if claims print is dark enough to be legible • Attach post-it or other notes • Use staples or paper clips • Mark up claims with highlighters • Use circles or other marks on claims • Attach anything to claims other than requested extra information • Add notes or instructions to your claims • Send unnecessary attachments • Submit copied claims forms • Give insurers, managed care plans or other payers reasons to reject your claims (inaccurate, illegible, not covered, lacks dates or other critical information)