Billing for Clinical Services
INTRODUCTION | BILLING RESOURCE | SECTION ONE | SECTION TWO | SECTION THREE | SECTION FOUR | SECTION FIVE | SECTION SIX | SECTION SEVEN | SECTION EIGHT | SECTION NINE |
This is an archived project that was created in 2014. For more information about this project, contact [email protected].
Local health departments are facing shrinking federal, state and local budgets. Although public health has traditionally been free, the cost of providing preventive and clinical services such as immunization as well as HIV, STI, and TB testing has been growing for health departments. LHDs play an integral role in the changing landscape of the Affordable Care Act and will continue to provide services for their community.
Even with expanded insurance coverage, gaps will remain and LHDs will need to develop a way to provide services to insured patients as well as those left uninsured. In order for LHDs to be able to provide preventive and clinical services regardless of insurance status, they may need to develop the capacity to bill third party payers. LHDs should be compensated by billing Medicare, Medicaid and private insurance companies for immunization, HIV, STI, TB testing and care, and other clinical services.
This site should serve as a guide and a resource for LHDs in building capacity to bill third party payers for clinical services. Whether your LHD is just starting the process to be able to bill or already has contracts with private insurance companies, NACCHO’s Billing for Clinical Services Toolkit has resources, templates, and manuals to help with your process.
Where to Start
NACCHO's Billing for Clinical Services Toolkit was designed to help make navigating the billing process easier for local health departments. In this toolkit you can find resources, guides, and templates on all aspects of billing.
To access the Billing for Clinical Services Toolkit, please click on the “Toolkits” drop-down menu and select “Billing for Clinical Services.” There are more than 300 resources available. To download any of the tools, you will need to register or use your current log-in with NACCHO’s web site.
Toolkit Structure
Below is the structure of the toolkit based on the order of the billing process.
- (01) Definitions, FAQS & Glossary
- (02) Getting Started
- (03) Laws and Regulations
- (04) Workforce Development
- (05) Clearinghouses
- (06) EHR/EMR
- (07) Medicaid/Medicare
- (08) Private Insurers
- (09) Credentialing
- (10) Contracting
- (11) Financial/Fee Policies
- (12) Patient Intake
- (13) Coding
- (14) Coding Quality Assurance
- (15) Claim Submission
- (16) Billing Remittance Advice
- (17) State Billing Guides
- (18) Immunization Tools
- (19) HIV Tools
- (20) STI Tools
- (21) TB Tools
- (22) Other Clinical Services
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About This Tool
This resource was developed to help health departments (HDs) with varying knowledge, understand the billing for clinical services process. This tool will help users determine what is needed to build general billing capacity and easily access tools that best meets their needs.
Other Key Resources to Consider:
- Health department peers and partners, community health centers, local hospitals, commercial labs, state insurance departments, state Medicaid and CHIP programs, and other medical practices who have knowledge of/experience with billing
- State Billing Guides
- Improving Reimbursement for Health Department Clinics Community of Practice (CoP) - an online portal for collaboration that allows members to access expertise and share experiences, success stories, tools, and ways of addressing barriers in planning and implementing billing systems
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Why consider billing for clinical services
a. Changing healthcare environment offers new billing opportunities
- Expanded insurance coverage under the Affordable Care Act
- (07) Medicaid/Medicare- Zooming in on Health Reform: Understanding Impact of ACA on local level- Interactive maps provide information on how the number and composition of individuals enrolled in Medicaid or without insurance could change with Medicaid expansion
- (20) STI Tools- Policy and Funding Landscape Impacting Third-Party Billing for STD-Related Services – Pages 2, 3 and 5 highlight the effects of coverage expansion on HD clinics and important questions for consideration
- New coverage of preventive services
- Opportunities to contract with third party payers
- Roles of HDs
b. Public health financing
- (20) STI Tools - Policy and Funding Landscape Impacting Third-Party Billing for STD Related Services
- (02) Getting Started – Upp's Public Health Claims Management Resource Center - Resources on the need for health departments to generate revenue in the changing health system
c. Understanding the landscape of the safety net in your jurisdiction
- Safety net providers that may be available in your community
- (02) Getting Started- Find Shortage Areas: HPSA & MUA/P by Address - Identification of Health Professional Shortage Areas (HSPAs) and Medically Underserved Areas/Populations (MUAs/Ps)
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How to decide if billing is appropriate for your health department
a. Assess HD infrastructure to bill for services
- (06) EHR/EMR- Electronic Practice Management System - This section of the California State Billing Guide describes the steps taken to ensure access to a functional electronic billing system
- EHR/EMR- Information on some of the software solutions including electronic health records and practice management (registration, billing, etc.)
- (06) EHR/EMR- Regional Extension Centers - List of Regional Extension Centers (RECs) that help providers adopt and use electronic health records (EHRs)
- (06) EHR/EMR- Select or Upgrade to a Certified EHR
b. Consider state statutes or administrative billing regulations
- (03) Laws and Regulations – State Legislative Update – ASTHO's table of state legislation that relates to billing for services provided by HDs
- (03) Laws and Regulations - Confidentiality for Individuals Insured as Dependents – Guttmacher Institute's report on confidentiality for individuals insured as dependents or spouses
- (03) Laws and Regulations - State Health Department Billing for HIV/AIDS and Viral Hepatitis Services – NASTAD's report addresses broadly relevant legal issues such as authority to bill, authority to receive reimbursement, and patient confidentiality
- (20) STI Tools- Insurance Billing for Sensitive Health Services: Statutory and Regulatory Analysis - A report from Temple University's Public Health Law Research (PHLR) group that explores state-level legal barriers to STD clinics (and other public clinics) billing third parties for services and was created in collaboration with The Division of STD Prevention at the Centers for Disease Control and Prevention.
c. Calculate costs and benefits to see if it makes financial sense to bill
- Collect data for a cost-benefit analysis
- Survey your clients to determine the third party payer mix and estimate expected changes from increased access to insurance coverage through the ACA
- (12) Patient Intake – Registration Form – An example of a patient registration form used by the Iowa Immunization Program and Medical Billing Services
- (02) Getting Started – ODH Patient Survey – A survey developed by the Ohio Department of Health to gather information on patients seeking immunization services
- (20) STI Tools – Survey about Insurance Coverage – A survey developed by the New York City Department of Health and Mental Hygiene that identifies payer mix and assesses willingness for clients to have their insurance billed
- Estimated cost of providing billable services - number of billable services provided in a given time frame and cost of providing services (i.e. service, supplies, staff costs, lab costs, etc.)
- Examine staff capacity
- (04) Workforce Development – NY Workforce Capacity –"Billing Workforce Capacity" section provides information on billing staff and their roles
- (01) Definitions, FAQs, & Glossary–Ohio: Local Health Districts FAQs About Billing – See page 3 for "How much extra staff is needed for billing?"
- Job Descriptions
- Estimated reimbursement rates
- (11) Financial/Fee Policies- Physician Fee Schedule Search – Searchable database of Medicare reimbursement for services as identified by billing codes
- (11) Financial/Fee Policies- Consumer Cost Lookup - Database of the "usual and customary rates" for services per geographic area.
- Cost-benefit templates
- (11) Financial/Fee Policies- Local Health Jurisdiction Cost Benefit Assessment Tool - An Excel-based guide that generates cost/benefit analysis for billing payers for services provided at HD
- (19) HIV Tools- Technical Assistance: Costing Tool Overview- An Excel-based software tool that generates cost information that can be used to assess billing costs/revenues
- (11) Financial/Fee Policies – CMD Revenue Calculator – An online calculator that can be used to get an overall assessment on billing costs and revenue
- Survey your clients to determine the third party payer mix and estimate expected changes from increased access to insurance coverage through the ACA
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How to decide which billing approach makes sense (i.e. in-house or outsourcing)
- (02) Getting Started- Should you outsource your medical billing? – Outlines the things to consider when deciding whether or not to outsource billing, such as cost and infrastructure needed
- (02) Getting Started- Decision Making Factors: When to Outsource - Covers the estimated cost of outsourcing
- (02) Getting Started- Advantages and Disadvantages of Hiring a Billing Company
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How to bill in-house
See Section Five: How to partially or fully outsource billing (below) to access tools for tools on outsourcing certain billing functions
a. Build billing infrastructure and utilizing staff
- Billing hardware/software - See more in Section Two a. Assess HD infrastructure (above) to bill for services
- (06) EHR/EMR - Billing Software Fact Sheets – Fact sheets include information on the functionality and affordability of eight software and website options
- (17) State Billing Guides - WA State/Local Health Jurisdiction: Immunization Billing Resource - Guidance on selecting a billing system
- EHR/EMR
- Considerations for billing staff
b. Establish fee schedules and clinic policies
- Fee schedules
- (11) Financial/Fee Policies - CA Guide Fee Schedule - Information on determining fees and creating a fee structure
- (11) Financial/Fee Policies - Fees & Fee Structure Information - Information on fees and creating a fee structure
- (11) Financial/Fee Policies - Sliding Fee Scale
- Billing policies - See Section Four d. Develop Standard Operating Procedures (below) for more information
- (17) State Billing Guide - Buncombe County Department of Health Billing Guide for FY 2014 - Policies and procedures around billing and sliding fee scales
- (11) Financial/Fee Policies - PH Billing Policy – Example of billing policy from Deschutes County Health Services
c. Build Capacity for Coding
- (13) Coding- Overview of Coding
- (13) Coding- Modifier Fact Sheets– List of fact sheets on modifiers (procedure codes that add information or change the description of a service to improve accuracy or specificity)
- (13) Coding - CMS Offers ICD-10 and Ver. 5010 Resources for Physicians
- (07) Medicaid/Medicare - Medicare Preventive Services – Quick reference tool lists codes for and descriptions of preventive services covered by Medicare
- (13) Coding- New CPT Modifier for Preventive Services – Document outlines how a new modifier may be used to identify preventive services
- Coding Quality Assurance - See Section Nine How to develop a quality assurance program and maximize billing revenue (below
- Coding for Clinical Services:
- Coding Hepatitis Services
- Coding HIV Services
- Coding Immunizations
- Coding STD Services
- Coding TB Services
d. Develop Standard Operating Procedures (SOPs)
- (12) Patient Intake - Patient Flow Process - A template that describes the patient registration and claims process (i.e. SOPs)
- Patient registration and provider encounters
- Intake and encounter Forms:
- Appointment/Check-in Procedures
- (12) Patient Intake - Identification of Patient Information - Instructions on collecting the required information from patients needed for the billing process
- Encounter Form- Samples of encounter forms (also known as superbills, that capture health care CPT codes and ICD CM codes completed during a patient's office visit) from immunization, STD and TB clinics
- Insurance Verification
- (12) Patient Intake - Insurance Verification
- (12) Patient Intake – Independent Insurance Eligibility Verification: Cost/Benefit – A report from Arizona Partnership for Immunization (TAPI) that outlines the insurance eligibility verification process and its importance
- Formalizing Check-out Process: Implementing a structured check-out process allows HDs to collect the co-pay, coinsurances or deductible and make payment arrangements before patient leaves the clinic.
- Intake and encounter Forms:
- Claims Process
- Claims submission
- Electronic Claims Transactions
- Completing the CMS 1500 Claim Forms
- Medicare Claims Submission
- (07) Medicaid/Medicare- Medicare Enrollment and Claim Submission Guidelines
- (15) Claim Submission - Electronic Billing and the Medicare Claims Submission Process
- (15) Claim Submission- COB: Coordination of Benefits - Illinois state insurance office webpage describes the process of coordinating benefits to bill multiple payers
- Posting payments - This process includes receipt and documentation of payment from payers and/or clients
- (12) Patient Intake - How To Read Your Explanation of Benefits Example - Here is a template on how to read the explanation of benefits for Blue Cross/ Blue Shield. Each state has their own version of this document.
- Remittance Advice- Remittance Advice summarizes payments made by insurers to reimburse medical providers for the services billed
- (16) Billing Remittance Advice - Health Care Payment and Remittance Advice - Medicare claim adjudication and payment information
- Follow-up of claims, when no response or payment is received from payer:
- (15) Claim Submission - 5 Fundamentals to Efficient Follow-Up - An outline of key steps to follow up on claims submission
- Management of denied claims
- Denials- Insurance denials and next steps
- Adjustment codes:
- (13) Coding- List of Claim Adjustment Reason Codes - WA Publishing Company Lists CARCs to communicate why a claim or service line was paid differently than it was billed
- (13) Coding- List of Remittance Advice Remark Codes - WA Publishing Company Lists RARCs to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or to convey information about remittance processing
- Clean Claims - Guidance on submitting "clean claims" - claims that have all information necessary to process a claim
- (16) Billing Remittance Advice – GA Appeals Process - Steps to appeal to insurance companies when the insurance company has wrongfully denied a claim
- (11) Financial/Fee Policies - Balanced Billing, Collection Procedures and more from NYSDOH - A section from the NYSDOH Immunization Billing Guide that escribes balanced billing, minimizing outstanding balances, collection procedures, and adjustments to billed claims
- Claims submission
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How to partially or fully outsource billing
a. Select and contract with a medical billing service provider or clearinghouse
- (02) Getting Started- Advantages and Disadvantages of Hiring a Billing Company - Potential advantages and disadvantages of hiring a billing company and important questions to ask when negotiating billing contracts that can identify potential risk and/or benefits
- (02) Getting Started - RFP for a Medical Billing Vendor - Request For proposal example to set up an operational medical billing program with an outside vendor created by City of Hartford
- (02) Getting Started- Guide to Selecting a Medical Billing Service
- Clearinghouse
b. Build billing infrastructure and attain staff
- EHR/EMR- See Section Two a. Assess HD infrastructure (above) to bill for services
- Job Descriptions
- (04) Workforce Development - Receptionist Job Description - An example of a job description for a receptionist that includes collecting payment/insurance information.
- (04) Workforce Development - Enrollment Specialist Job Description
- (04) Workforce Development - Functional Job Descriptions – Describes the following jobs include: front office registration, insurance verifier, cashier/checkout, and credentialing specialist
c. Establish fee schedules and clinic policies
- Fee schedules
- (11) Financial/Fee Policies - CA Guide Fee Schedule - Information on determining fees and creating a fee structure
- (11) Financial/Fees Policies - Fees & Fee Structure Information - Information on fees and creating a fee structure
- (11) Financial/Fee Policies - Sliding Fee Scale - An example of a sliding fee scale
- Billing policies
- (17) State Billing Guide - Buncombe County Department of Health Billing Guide for FY 2014 - Policies and procedures around billing and sliding fee scales
- (11) Financial/Fee Policies - PH Billing Policy - The billing policy from Deschutes County Health Services
- See Section Four d. Develop Standard Operating Procedures (above) for information that may help develop billing policies related to the SOPs
- Hardship Policy
d. Develop Standard Operating Procedures (SOPs) - See Section Four d. Develop Standard Operation Procedures (above)
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How to get providers credentialed with a health plan
a. Understand the credentialing process
- (09) Credentialing - Overview of Health Plan Credentialing - A presentation from AHIP to define the role and purpose of credentialing, requirements, and standards. Page 12 has an easy to read 1 page chart describing the Health Plan Credentialing Workflow
b. Identify credentialing requirements
- (09) Credentialing - State Credentialing Application Forms - A list of individual state credentialing application forms
- Universal Credentialing
- Council for Affordable Quality Healthcare or CAQH - A list of tools about CAQH, a centralized database used by most commercial health plans that simplifies credentialing process
- (09) Credentialing- CAQH Universal Provider Datasource Participating Organizations
- States laws relevant to streamlining and standardizing credentialing process
c. Gather and submit credentialing documents
- (09) Credentialing - AL Credentialing Document List Form – A template of credentialing documents that are commonly required by a majority of plans for credentialing
- (09) Credentialing - IN Credentialing Provider Information Collection Form - A template of credentialing information typically requested
- National Provider Identifier
- (09) Credentialing- Clinical Laboratory Improvement Amendments (CLIA) - CMS website on the CLIA Program, a program that ensures quality laboratory testing
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How to enroll with public payers (Medicaid, Children’s Health Insurance Program (CHIP), and Medicare)
a. Access your State Medicaid and CHIP provider enrollment requirements
- (07) Medicaid/Medicare- Medicaid and CHIP Program Information by State - Links to state Medicaid agency websites and information on state Medicaid and CHIP provider enrollment processes
b. Access Medicare provider enrollment requirements
- (07) Medicaid/Medicare - How To Enroll as a Medicare Provider
- Medicare Enrollment
- (07) Medicaid/Medicare- Medicare Enrollment and Claim Submission Guidelines
- (07) Medicaid/Medicare- Medicare Fee-for-Service Provider Enrollment Contact List- A contact list for the contractors serving your State or jurisdiction who will process your enrollment application
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How to contract as an in-network provider with private payers (Blue Cross Blue Shield, Aetna, Humana, etc.)
a. Understand the contracting (provider enrollment) process
- (10) Contracting- Becoming an In-Network Provider:The Health Department Perspective - An overview of the process of contracting for HDs
b. Identify health insurance plan models available in your area
- (10) Contracting - Third Party Payer Relationships - Introduction to provider enrollment and types of third party payers
- (08) Private Insurers - Large Health Insurance Companies by State - A tool to search for health insurance plans by state.
- Survey client payer mix
- (12) Patient Intake – Registration Form – An example of a patient registration form used by the Iowa Immunization Program and Medical Billing Services
- (20) STI Tools – Survey about Insurance Coverage – A survey developed by the New York City Department of Health and Mental Hygiene identifies payer mix and assesses willingness for clients to have their insurers billed
c. Send a Letter of Intent to payers
- (10) Contracting - Sample Intent Letters – Examples of letters of intent for contractual agreements with third party payers.
d. Determine if a contract is necessary
- (17) State Billing Guides–WA State/Local Health Jurisdictions: Immunization Billing Resource - “Choosing to Contract or Not, Contract Basics” describes how to decide if a contract is necessary
- Explore the option Memorandum of Understanding (MOU) to bill without a contract
- (17) State Billing Guides–WA State/Local Health Jurisdictions: Immunization Billing Resource - Describes the purpose of a MOU
e. Review contract or provider service agreement and negotiate contracts
- (10) Contracting- Webinar Recording: Revenue Cycle Management: Contracting with Payers - A webinar that provides guidance on the process of negotiating fee schedules and executing contracts with third-party payers
- (10) Contracting- Speaking to Private Insurance Contract Reps - A script for speaking with private insurance contract representatives
- (19) HIV Tools - Strategies for HIV Medical Providers Contracting with Health Insurers - The guide outlines eight steps for contracting with health insurance plans and managed care organizations (MCOs)
- Use your HDs legal counsel to review contract
f. Approve contract
- (10) Contracting- Sample Board Letter for Contract Approval - Provides an example of a contract approval letter
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How to develop a quality assurance program and maximize billing revenue
A quality assurance program can improve claims management, increase cash flow, assure compliance with applicable laws and regulations, and ensure timeliness and accuracy of billing and collections.
a. Develop a quality assurance program
- Quality Assurance - Compliant coding that follows regulations established by the Inspector General lowers potential audit risk (i.e. ensuring accurate coding and clean claim submission)
- (13) Coding - Policy for Proper and Accurate Coding - A template and example of coding polices for quality control
- (14) Quality Assurance - Why Are Coding and Documentation So Important for Medical Billing?
b. Learn how to perform a medical audit
- (14) Quality Assurance - What is Medical Auditing? - A website that introduces medical auditing and describes the need to implement an audit
- (14) Quality Assurance - How to Perform a Physician Practice Internal Billing Audit- A presentation that explains why physician practices need to conduct internal billing audits and how to perform an internal billing audit
c. Develop a quality assurance compliance program
- (14) Quality Assurance - Compliance and The Billing Process - Describes a compliance program as a quality assurance strategy to prevent the submission of erroneous claims or engagement in unlawful conduct
- (14) Quality Assurance - OIG Compliance Program for Individual and Small Group Physician Practices – Notice on a voluntary compliance program guidance for individual and small group physician practices
d. Improve billing efficiency
- Training the billing staff and consulting with billing specialist/coding experts
- Identify and address problem areas and inefficiencies in claims
- (17) State Billing Guides – Kansas Immunization Billing Stakeholder Group Guide - An Excel-based tool intended to help HDs identify specific weaknesses in their billing system
- Clean Claims - Improve cash flow by ensuring "clean" claims on first submission and by reducing denials
- Claims follow-up (if no response from payer or payment is not received)
- (15) Claim Submission - 5 Fundamentals to Efficient Follow-Up- Outline of key steps in following up on claims submission
- Resubmit and manage denied claims - See "Management of Denied Claims" in Section Four d. Develop Standard Operation Procedures (above)
- Resubmit and manage denied claims - See "Management of Denied Claims" in Section Four d. Develop Standard Operation Procedures (above)
- Determine if your HD should use an external billing company - See Section Three: How to decide which billing approach (i.e. in-house or outsourcing) makes sense and Section Five: How to partially or fully outsource billing
- Review and update your SOPs - See Section Four. d. Develop Standard Operating Procedures (above)
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NACCHO Webinar: Becoming an In-Network Provider: The Health Department Perspective, November 2013
- Speaker: Scott Coley, MS, MPH – New York State Health Department
- Speaker: Robin Iszler, RN – Central Valley (ND) Health District
- Speakers: Vicky Poirrier and Sharon Gates – Mississippi State Department of Health
- Speakers: Various staff – NACCHO
- Recording [YouTube link]
- Slides [PDF]
- Q&A session answers [PDF]