"Second Review" Process for Revenue

State: FL Type: Model Practice Year: 2013

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The Volusia County Health Department (VCHD) is a governmental subdivision of the Florida Department of Health (FL DOH), one of 67 county partnerships between the State and County governments to provide health services to the people of Florida. Volusia County, Florida has an approximate population of 494,593 residents. VCHD serves as the safety net for residents who do not have a medical home and is a leader in the community for public health issues.

VCHD provides services to a population of clients who are frequently below the federal poverty level, and may have no personal ability to pay. Traditionally, Medicaid is the payor source for a large portion of the services delivered each year. Over the past five years, however, we have seen a consistent and significant increase in clients seeking services who have no resources and no payor source.

 

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Volusia County Department of Health
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"Second Review" Process for Revenue
The Volusia County Health Department (VCHD) is a governmental subdivision of the Florida Department of Health (FL DOH), one of 67 county partnerships between the State and County governments to provide health services to the people of Florida. Volusia County, Florida has an approximate population of 494,593 residents. VCHD serves as the safety net for residents who do not have a medical home and is a leader in the community for public health issues. VCHD provides services to a population of clients who are frequently below the federal poverty level, and may have no personal ability to pay. Traditionally, Medicaid is the payor source for a large portion of the services delivered each year. Over the past five years, however, we have seen a consistent and significant increase in clients seeking services who have no resources and no payor source. In the period from 2006 to 2010, VCHD experienced a 99% increase in the number of clients who were at or below 100% of the federal poverty guidelines. We projected an additional 25% increase during FY 2011-2012; the actual results were more staggering as we saw an increase of 45% of clients below the federal poverty guidelines. This is a 214% increase from 2006 to today. (Graph 1) The VCHD Finance and Accounting Department (“Finance”) team recognized this significant trend. They formed a hypothesis that a "second review" would disclose services that would become billable to Medicaid retroactively for recipients who became eligible Medicaid after the services were provided. Florida Medicaid allows billing for services for up to twelve months from the date of service. To provide quantitative proof-of-concept evidence, in July 2010 we developed a project that enhanced our existing local Billing and Accounts Receivables process. There were no additional cost arising from this project. Records in the first two months of this pilot program confirmed that this change would provide significant additional revenue over the fiscal year. The actual "Net Added Value" was $91,637.20 in the pilot year and $126,497.88 for this fiscal year. This project has provided convincing financial proof of concept that can be used by other county health department billing operations to generate additional revenue. Absent this proof of concept, the previously accepted thinking was that these amounts were too small to justify the staff time to review. Now we know that this is not the case. Currently, these funds support major direct client health center operations throughout Volusia County. We estimate that this could equate to 700 additional visits per year for clients who have no ability to pay. In the present economic climate, VCHD has sustained the level of services offered to the residents of Volusia County. For this team to achieve this level of revenue recovery supports the VCHD in its mission to extend these services to the citizens of Volusia County and is indeed an achievement worthy of this award.
ResponsivenessThe public health issue that this practice addressesVCHD clinical programs consists of four medical offices and two Dental offices located throughout our county. We also provide outreach services within our community. County health departments provide services to a population of clients who are frequently below the federal poverty level, and may have no personal ability to pay. The FL DOH produces a Sliding Fee Scale to help make services more affordable for clients. Financially eligible clients are not required to pay full charges to receive most FL DOH services. FL DOH revises its sliding fee scales each year after the federal government has produced their annual poverty guidelines. Florida county health departments have experienced several reductions in funding over the past four years. The VCHD experienced a ten percent reduction in state and federal funding this year. Concurrently, we have seen an increase in clients, that at the time of service, qualified for a “zero percent” under the FL DOH Sliding Fee Scale who are eligible for services at no cost. These clients do not have active Medicaid and do not have pending applications for Medicaid at the time of service. The services provided to these clients is billed correctly at $0.00 based on the financial eligibility information that was available, the federal poverty guidelines and the FL DOH Sliding Fee Scale. By introducing this "second review" process, the Finance team has demonstrated a methodology that will enhance revenues and preserve the ability to serve clients. Identifying services for which Medicaid retroactive billing may be made enables the VCHD to continue or offer services to other clients unable to pay. It is important to note that if client has a Medicaid application in pending status at the time a service is provided, that client is not captured in this project. Those services are part of our normal billing process. The process used to determine the relevancy of the public health issue to the communityOver the past five years the Volusia County Health Department (VCHD) has seen a consistent and significant increase in clients seeking services who have no resources and no payor source. In the period from 2006 to 2010, the VCHD experienced a 99% increase in the number of clients who were at or below 100% of the federal poverty guidelines. We projected an additional 25% increase during FY 2011-2012. The actual results were more staggering as we saw a 45% increase. The Finance team recognized this significant trend and that Florida Medicaid allows billing for services for up to twelve months from the date of service. They formed a hypothesis that a "second review" would disclose services that would become billable to Medicaid retroactively for recipients who became eligible Medicaid after the services were provided.  How the practice address the issue The State of Florida has a number of performance standards and processes that require and define accountability as expected by the taxpayers of Florida. Accountability for funds received is a primary function of by the VCHD Finance and Accounting Department (“Finance”). Our mission is to provide the infrastructure to support Public Health Services by maintaining and providing financial management. Chapter 154 of the Florida Statutes establishes the framework for the delivery of public health services at the county level. This statute outlines a contractual partnership between the state and each county, as well as general service delivery, funding, and reporting requirements. This statute requires the county health department to administer 43 public health programs. Of these 43 programs, 32 have zero or inadequate funding; only 11 have adequate dedicated funding. Programs without adequate funding are supported by Medicaid cost-based reimbursement (CBR) fees and general revenue. The funds generated by this project support direct client health center operations throughout Volusia County. We estimate that this could equate to 700 additional visits per year for clients who have no ability to pay; and has contributed to sustaining the level of services offered to the residents of Volusia County.   Innovation Evidence based strategies used in developing this practiceCounty health departments traditionally rely on reports generated from the state practice management system. When a client comes in for a service, the standard procedure is to verify and update Medicaid eligibility. If a client receives only one service, there is no report or mechanism that alerts the team that someone has become eligible for Medicaid. The only method today is to have someone consistently review the Florida Medicaid Management Information System (FMMIS) for subsequent eligibility. In the first year of this project, Finance looked at services for clients who were at “zero percent” (based on Federal Poverty Guidelines) and were billed correctly at $0.00. We also reviewed all of our clients that had unpaid balances that were ready to be written off or sent to collections. This year, Finance enhanced its “second review” process by checking into patients’ Medically Needy Share of Cost Medicaid (Share of Cost) enrollment status. During our systematic review of client statements and FMMIS, we discovered that some of the clients researched qualified for Medicaid Share of Cost. If the patient’s Medicaid Share of Cost had been opened in the recent past, we checked their current enrollment status. If the amount the client owed meet or exceeded the Share of Cost amount, Finance submitted a bill to Department of Children’s Case Management Unit. Finance now proactively bills our services once the Medicaid Share of Cost is reached. If the client has made a payment, we process a refund for the client. The team processed 14 refunds of these this year. It is important to note that if client has a Medicaid application in pending status at the time a service is provided, that client is not captured in this project. Those services are part of our normal billing process. The practice is new to the field of public healthThe process used to determine that the practice is new to the field of public healthWe checked with other county health departments (CHDs) on their processes for billing Medicaid and other insurance. CHDs traditionally rely on reports generated from the state practice management system. When a client comes in for a service, the standard procedure is to verify and update Medicaid eligibility. All CHDs hold the billing for services if there is a Medicaid application pending. It is important to note that if client has a Medicaid application in pending status at the time a service is provided, that client is not captured in this project. Those services are part of our normal billing process. How this practice differs from other approaches used to address the public health issueAll CHDs hold the billing for services if there is a Medicaid application pending. This project goes beyond that as VCHD Finance looks at services for clients who were at “zero percent” (based on Federal Poverty Guidelines) and were billed correctly at $0.00. We also systematically review all of our clients that have unpaid balances that were ready to be written off or sent to collections. This year, Finance enhanced its “second review” process by checking into patients’ Medically Needy Share of Cost Medicaid (Share of Cost) enrollment status. Finance now proactively bills our services once the Medicaid Share of Cost is reached. If the client has made a payment, we process a refund for the client.
Primary stakeholders VCHD Business Office and the citizens of Volusia County LHD's roleIt is the responsibility of the Volusia County Health Department to promote and protect the health and safety of all Volusia County residents and visitors by preventing and controlling acute, chronic and infectious disease, promoting access to basic health services for persons unable to access care from the private sector. County health departments provide services to a population of clients who are frequently below the federal poverty level, and may have no personal ability to pay. The FL DOH produces a Sliding Fee Scale to help make services more affordable for clients. Financially eligible clients are not required to pay full charges to receive most Department of Health services. The FL DOH revises its sliding fee scales each year after the federal government has produced their annual poverty guidelines. A key to that mission is the financial health of the county health departments, so that essential health services are available to all residents, even the poorest. Recovery of otherwise overlooked Medicaid revenues promotes the financial health of the county health department in continuing to perform this mission. To collect from appropriate revenue sources ensures that we remain good stewards of the taxpayers' funds. Stakeholders/partners The VCHD Business Office was 100% responsible for the planning, development and implementation of the practice. Analysis, development and coordination of the project were handled internally between VCHD Administration and VCHD Finance. No collaboration with community shareholder was used in this process Lessons learned During the first year of the project, the VCHD Finance team had a new employee, a retiring employee, a new Billing Supervisor, and was short-staffed during a turnover period. To implement this policy and procedure change in a period of staffing change was a risk, and an obstacle to overcome. This team looked at an aspect of accounts receivable operations normally overlooked in conventional wisdom as not worth the effort, and found significant additional revenues for very little additional effort. Finance was recognized in 2012 with the NACCHO Certificate of Promising Practice. In April 2012, Finance was recognized at our VCHD awards as the Team of the Year for this "Second Review Process". This project was showcased at the annual Department of Health Statewide meeting in May 2012. County health departments traditionally rely on reports generated from the state practice management system. When a client comes in for a service, the standard procedure is to verify and update Medicaid eligibility. If a client receives only one service, there is no report or mechanism that alerts the team that someone has become eligible for Medicaid. The only method today is to have someone consistently review the Florida Medicaid Management Information System (FMMIS) for subsequent eligibility. The "second review" process is a systematic review of client statements and FMMIS. In fiscal year 2010-2011 VCHD provided over 250,000 services. This generated over 64,000 encounter and consent forms which had to be reviewed for this project. This “second review” discovered 1,280 services that could be billed to Medicaid or other insurances. VCHD provided over 290,000 services in fiscal year 2011-2012. This generated over 70,000 encounter and consent forms which had to be reviewed for this project. This “second review” uncovered 1,194 encounters that could be billed to Medicaid or other insurances. A spreadsheet was maintained to track these services. Each client's insurance status was reviewed and verified. Those accounts that could be billed were tracked and updated when a payment was received. Each fiscal year the log is totaled, yielding an actual net amount of additional revenue. Time FrameThis is an on going project as it continues to bring in revenue that supports our public health operations. ImplementationMedicaid Eligibility can be retro-activate up to 90 days-SuperBills without a pay source are reviewed-Other sources reviewed:-Pending Collection Status-Statement reports Additional input from patient/clerical/financial counselor FLMMIS researched for Medicaid / other coverage on date of service HMS is updated with valid insurance information and services billed Maintain log of with the following data for tracking: - Client name - Date of Birth - Insurance - Date of Service Amount billed/collected/refunded Lessons learned A key to that mission is the financial health of the county health departments, so that essential health services are available to all residents, even the poorest. Recovery of otherwise overlooked Medicaid revenues promotes the financial health of the county health department in continuing to perform this mission. To collect from appropriate revenue sources ensures that we remain good stewards of the taxpayers' funds. While this process benefits VCHD with much needed revenue, we were also able to process 165 client refunds. It was a was a wonderful experience to have a client call when she received a $35.00 refund check. She asked if it was valid. When she was told it was, she began to cry. She stated that she didn’t know how she was going to buy diapers for her baby and that now she could. Cost of implementationThe total additional net revenue collected during this two year project was $218,135.08 ($91,637.20 in FY 10-12 and $126,497.88 in FY 11-12). In an era of limited resources, resource recovery is a key to our agency's financial viability. The success of this innovation is exceptional in the way that such additional revenues were recovered with such a small amount of extra effort. There was no additional cost to start this process. The staff worked on this process during normal work hours dedicating about 5 hours per week (total) on the project.
Accountability for funds received is a primary function of by the VCHD Business Office. Our mission is to provide the infrastructure to support Public Health Services by maintaining and providing financial management. Objective 1: Enhance Revenue Objective 2: Positively Impact the citizens of Volusia County Objective 3: Improve internal operations Objective 1: Enhance Revenue. Florida county health departments have experienced several reductions in funding over the past four years. The VCHD experienced a ten percent reduction in state and federal funding this year. This means that VCHD relies on fees to support the framework for the delivery of services. Medicaid the payor source for a large portion of the services delivered at the VCHD and makes up about 32% of the total revenue generated each year. In fiscal year 2010-2011 VCHD provided over 250,000 services. This generated over 64,000 encounter and consent forms which had to be reviewed for this project. This “second review” discovered 1,280 services that could be billed to Medicaid or other insurances. Out of these, 871 services were priced at $5.00 each, with the remaining services priced at different rates. VCHD provided over 290,000 services in fiscal year 2011-2012. This generated over 70,000 encounter and consent forms which had to be reviewed for this project. This “second review” uncovered 1,194 encounters that could be billed to Medicaid or other insurances. Out of these, 488 encounters were priced at $5.00 each, with the remaining services priced at different rates A spreadsheet was maintained to track these services. Each client's insurance status was reviewed and verified. Those accounts that could be billed were tracked and updated when a payment was received. Each fiscal year the log is totaled, yielding an actual net amount of additional revenue. The total additional net revenue collected during this two year project was $218,135.08 ($91,637.20 in FY 10-12 and $126,497.88 in FY 11-12). No additional staff was required. In an era of limited resources, resource recovery is a key to our agency's financial viability. The success of this innovation is exceptional in the way that such additional revenues were recovered with such a small amount of extra effort. By introducing this "second review" process, the Finance team has demonstrated a methodology that will enhance revenues and preserve the ability to serve clients. Identifying services for which Medicaid retroactive billing may be made enables the VCHD to continue or offer services to other clients unable to pay. Objective 2: Positively Impact the citizens of Volusia County. County health departments provide services to a population of clients who are frequently below the federal poverty level, and may have no personal ability to pay. Over the past five years, however, the county health department has seen a consistent and significant increase in clients seeking services who have no resources and no payor source. In the period from October 2006 through September 2010, the county health department experienced a 99% increase in the number of clients who were at or below 100% of the federal poverty guidelines. There was a 49% increase in 2010 alone. Identifying services, for which Medicaid retroactive billing may be made, enables the county health department to continue to offer services. This "second review" process generated additional revenue for previously provided services. Currently, these funds support major direct client health center operations throughout Volusia County. We estimate that this could equate to 700 additional visits per year. This allows the VCHD to continue to be a safety net in our community. In the present economic climate, the VCHD has sustained the level of services offered to the residents of Volusia County. It is interesting to note that in FY 2010-2011 293 of the encounters and in FY 2011-2012 481 of the encounters researched were originally were billed to clients on a sliding fee scale (Federal Poverty Guidelines) in the amount of $15,882.40 and $25,493.27 respectively. According to Department of Health Accounts Receivable Policy, these accounts could have gone to collections. The “second review” enabled the Volusia County Health Department to free the clients from this liability. In FY 2011-2012, no clients were sent to collections. In addition, 165 clients received a refund or had the amount credited to new services.   Objective 3: Improve internal operations. In 2010 before the project was implemented, our client bad debt was at $348,520. Of this, $261,446.06 was sent to collections. With the implementation of this project, our bad debt is under $131,976.63 in FY 11-12. This represents a 62% reduction in the bad debt carried by VCHD. By doing this second review process, our client collection rate has increased from 87.5% to 92.7%. In FY 11-12 no clients were sent to collections. The Division of Public Health Statistics and Performance Management for the Florida Department of Health reviews all billing that is submitted to Medicaid. They compile the data for all 67 county health departments. The data is compiled by the Senior Health Policy Analyst for Health Administration. The source of the data is the Medicaid Data Warehouse. The data reviews all Medicaid claims that were submitted, paid and/or denied by quarter. The claims that are denied are examined to determine if the errors were “non-correctable” or “correctable”. The correctable claims are then reviewed for errors: Provider file errors, eligibility issues, diagnosis code or procedure code errors and utilization. Each of the 67 counties is ranked for their efficiency in billing (no error rate). The Volusia County Health Department consistently ranks in the top 10 most efficient counties, ranking 8th in the last 2 quarters. The last quarter we had a 98.3% efficiency rating as compared to the entire state at 94.8%. When compared to counties that are our peers in size (Large or Mega counties), the Volusia County Health Department ranks 2nd out of 22 peer counties.
Stakeholder CommitmentA key to that mission is the financial health of the county health departments, so that essential health services are available to all residents, even the poorest. Recovery of otherwise overlooked Medicaid revenues promotes the financial health of the county health department in continuing to perform this mission. To collect from appropriate revenue sources ensures that we remain good stewards of the taxpayers' funds. The total additional net revenue collected during this two year project was $218,135.08. No additional staff was required. SustainabilityThis project has provided convincing financial proof of concept that can be used by other county health department billing operations to generate additional revenue. Currently, these funds support major direct client health center operations throughout Volusia County. We estimate that this could equate to 700 additional visits each year. In the present economic climate, the Volusia County Health Department has sustained the level of services offered to the residents of Volusia County.
 
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