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Medi-Cal Paid Claims Reports Huh???

Medi-Cal Paid Claims Reports Huh???. Joanne Roberts, PHN Perinatal Services Coordinator Los Angeles County November 14, 2013. Objectives. Perinatal Services Coordinators will: Be able to interpret the information on the Medi-Cal Paid Claims Report

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Medi-Cal Paid Claims Reports Huh???

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  1. Medi-Cal Paid Claims ReportsHuh??? Joanne Roberts, PHN Perinatal Services Coordinator Los Angeles County November 14, 2013

  2. Objectives Perinatal Services Coordinators will: • Be able to interpret the information on the Medi-Cal Paid Claims Report • Understand why the Paid Claims Report is an essential component of quality assurance and monitoring

  3. What Is It? • Report of claims paid by Medi-Cal for a 6-month period: Jan-June and July-Dec • Fee-for-service only • Does not include Medi-Cal Managed Care, FQHC, RHC, IHC

  4. 3 Separate Reports • Delivery Only • Non-Delivery Only • CPSP Only

  5. Non-Delivery & Delivery Only • Non-Delivery: prenatal, postpartum, and global codes • Delivery Only: deliveries (excluding global billing codes) • Use to identify/recruit new CPSP providers

  6. CPSP Report • Health education, nutrition, and psychosocial services • CPSP bonuses: early entry and 10th visit • Monitor CPSP provider activity

  7. What’s in the CPSP Report? • County Name • Provider Type Code • Provider Specialty Code • Provider Legal Name • Provider Address, City, Zip Code

  8. What Does It Tell Me? • Who’s billing CPSP in your county? • Do you recognize all the names? • Non-CPSP providers? • Approved providers missing? • Different address? • Approved providers with unknown sites?

  9. What’s in the CPSP Report? • “Claim Count” • Number of services • “Total Billed Quantity” • Units of service • Example: • Claim count (# of services) = 50 • Total billed quantity (# units) = 147

  10. Claim Count & Quantity • Compare the numbers • Quantity usually 2-3 times more than Count • When Count = Quantity • Only 1-unit services are billed • Usually means bonuses only • Could be billing error

  11. Now for the Money! • Does the total amount paid fit with the provider type? • Is small solo practice making $200,000 for CPSP only • Is large hospital clinic making only $10,000

  12. Red Flags • Providers reimbursed more than expected • Misunderstanding • Intentional overbilling (fraud) • CPSP done at multiple sites billed from one site (other sites may not be CPSP approved)

  13. Red Flags • Providers reimbursed less than expected • Misunderstanding by provider staff • Biller not billing correctly: “Medi-Cal doesn’t pay.”

  14. Hospitals • Lower than expected reimbursement? • Billing departments and clinic staff don’t communicate • Clinic staff may not mark correct # units • Billers submit as claims “Quantity = 1” for all services, regardless of # of units provided • Hospital computers programmed to discard any claim below a certain amount ($25, $50)

  15. What Do I Do With It? • Review prior to calling/visiting any fee-for-service provider • Ask provider how billing is going? • Compare response to paid claims amount

  16. Example #1 PSC: Hi, I’m calling to schedule your annual CPSP quality assurance review. Office Manager: Oh, we’re not doing CPSP right now. PSC: Really, because the report I’m looking at shows that you billed $187,000 just for CPSP services between January and June of this year. Office Manager: That’s impossible!

  17. Example #2 PSC: Hi, I’m calling to schedule your annual CPSP quality assurance review. How’s everything going? Are you billing for CPSP? Office Manager: Everything’s great! We’re seeing a lot of CPSP patients and the billing is fine. PSC: Are you sure because I have a report that shows you haven’t been reimbursed anything in the last 6 months. Office Manager: (silence)

  18. Let’s Look at the Report Paid Claims Report Jan-Jun 2013 Volunteer needed!

  19. Next Steps • Update the billing codes used in the CPSP, Non-Delivery, and Delivery Only reports • Rename the column labels to be more self-explanatory • Continue relationship between MCAH and Medi-Cal to ensure uninterrupted availability of the Paid Claims Report

  20. Conclusion • Paid claims are invaluable to PSCs • The report’s not that complicated once you know what you’re looking at

  21. Billing Resources • Medi-Cal: www.medi-cal.ca.gov • Provider Manual, Bulletins, Learning Portal, contact Regional Representative • ACS/Xerox (Medi-Cal Fiscal Intermediary) • Telephone Service Center (TSC): 1-800-541-5555 • To leave a message for a Regional Representative, call the TSC then follow the prompts 11, 15, 14

  22. Thank you! Joanne Roberts, PHN (213) 639-6427 jroberts@ph.lacounty.gov

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