Some providers may still be hiding their heads in the sand when it comes to billing, but other provider organizations have had the good fortune to be prepared for and supported by NIATx collaboratives as they confronted a major change in the way they are paid for services.
Courtesy of health care reform, a significant number of providers are, for the first time, confronting the shift from lump-sum payments — the kind typically associated with federal or state treatment block grants — to an encounter and service-based billing system that requires them to bill a third party — typically Medicaid or a commercial health insurer — for each patient, and each service.
Substance use disorder (SUD) treatment providers in particular have been getting help learning to bill third-party payers from a “learning collaborative” developed for the Substance Abuse and Mental Health Services Administration (SAMHSA). Through a contract with JBS International Inc. and a subcontract with the University of Wisconsin, where NIATx is housed, consultants have helped participating providers solve payment related challenges.
Behavioral Healthcare recently talked to Janet Zwick, technical expert lead for JBS International, Jeanne Pulvermacher, NIATx project manager, and Elizabeth Strauss, NIATx coach, who presented a workshop, “That was then. This is now” at the NIATx/SAAS annual meeting.
As treatment providers are moving from being funded by the federal Substance Abuse Prevention and Treatment block grant to fee-for-service commercial insurance and Medicaid, they have to learn an entirely new set of strategies. No longer can they rely on the block grant payments, according to the NIATx team – and Zwick, who was formerly the single state authority in Iowa for the block grant, knows that this can be difficult.
“There might be conditions on the block grant, like having to serve a certain number of clients, but the bottom line is that the providers were guaranteed the money and they didn’t have to bill anyone,” Zwick says. While SAMHSA, which administers the block grant, doesn’t expect it to go away, it does expect it to be used for recovery services which aren’t paid for by insurance, instead of treatment, which is. “The way that they bill is going to be very different,” says Zwick. “They are billing for each service for each individual client.”
Here are some of the tips the three consultants shared:
1. Improve the collection rate. Using the NIATx model, which is based on process improvement, providers can learn how to calculate and track their collection rates. Even if a provider sends a correctly completed claim to the insurance company, the claim could be denied, explains Strauss. So, it is essential to see what an organization collects as well.
2. Verify individual eligibility and payer coverage.
o Sometimes people believe that they have health insurance and that it covers specific types of treatment, but they’re often mistaken, says Strauss. If a provider starts treatment without verifying coverage first, they risk collecting nothing at all. “Providers have found there are big holes in what they do,” she says. “One agency learned that they weren’t verifying insurance.”
o One treatment provider in Florida improved its Medicaid collections for therapeutic on-site services by 500% in one fiscal year, increasing revenue by $104,000. The key: simply confirming Medicaid eligibility, says Zwick. The program reassigned responsibilities so that one staff member could confirm that the patient was eligible for Medicaid, input the patient’s information into the clinical data system, and obtain treatment authorizations as needed.
3. Apply to become a provider. “Many programs we worked with hadn’t even started an application process to become a Medicaid or commercial insurance provider,” says Zwick, adding that getting those applications approved can take up to six months. “It’s a tedious process, and occasionally applications get lost.” The majority of the providers in the past year’s learning collaborative cohort had not even started the application process.
4. Obtain prior authorizations. Some services – particularly costly ones – require prior authorization by the insurance company. Even if a service is necessary and delivered to a patient, an insurance company won’t pay for it unless it was authorized before it was performed.
5. Verify appropriate clinician credentials. “This is a big deal,” says Strauss. “People are going to need more credentials in order to be in a commercial health insurance network,” she said. Make sure the clinician treating the patient is in network for the insurance that patient has. Some agencies are requiring clinicians to become licensed and credentialed within two years. “Third party insurance requires certain credentials in order to get paid,” says Strauss.
6. Obtain National Provider Identifier (NPI) numbers for providers. NPIs are required for billing Medicare, Medicaid, and private insurance. In New Hampshire, the collaborative worked providers get NPI applications completed.
7. Take credit cards instead of checks. One program learned that when it started allowing people to pay with credit cards instead of checks, a significant problem — bounced checks and payment delays — disappeared. Accepting credit card payments did not increase revenue, but it did increase available cash and therefore reduced the chances that the program itself would run short of funds.
“The point is that providers need to run their agencies like a business,” says Zwick.