WHO ARE WE?

PUBLIC HEALTH REVENUE PLAYBOOK 1

We have 30+ years of experience in the government sector—

Our engagements span 18 states, 100+ large counties and

5000 providers offices, with over 70 million Americans covered.

WHY DID WE START?

• Changing landscape with ACA implementation

• Shifting impact on public health

• Increased Medicaid enrollment

• Managed Care, HMOs, Supplemental Plans

• Patients and Providers unsure of coverage

PUBLIC HEALTH REVENUE PLAYBOOK 2

Specific Public Health Approach

PUBLIC HEALTH REVENUE PLAYBOOK 3

INITIAL ASSESSMENT

INSURANCE CONTRACTING

POLICIES & PROCEDURES

FEE SCHEDULE

BILLING & CODING

TRAINING

WORKFLOW MAPPING

CLAIMS PROCESSING

REPORTING

EVALUATION

PUBLIC HEALTH REVENUE PLAYBOOK 4

SUPPORT FOR SUSTAINABILITY

Contracting & Credentialing

Assistance

Revenue Analysis

Data Management

System Integration

On-Site Training &

Set-Up

Continuous Tech Support

User-Driven Development

Reasons to Bill Private Insurance

• Changing Landscape with ACA Implementation

• Existing Funding Source

• Increase Revenue

• Improve Customer Service

5

Contracting with Third Party Payers

Components to Begin the Contracting Process

• Fee Schedule Evaluation

• Updated/Current

National Provider

Identifier (NPI)

• Credentialing

• Payer Contracting

7

Fee Schedule Evaluation

• Vaccine for Children

– Current Administration Fee

• Private Stock Vaccines

– Purchase Cost

– 340B Providers/Prime Vendor Program

• Cost for Providing Services

– Include all billable services

• Customized/National Fee Analyzer

– OptumCoding

– PMIC Medical Fees

8

Updated/Current National Provider Identifier (NPI)

9

Credentialing

• Credentialing Specialist

– Ideally one person in the organization should be assigned this role

• Council for Affordable Quality Healthcare (CAQH) – ProView

– Used by PPO Networks, Health Plans & Government Payers

• Payer In-House Process

– Internal Credentialing

– Provider Type Specific

10

Payer Contracting • Contracting Specialist

– Excellent Communication Skills – Sales Personality – Organized and Persistent

• Popular Payers – Prioritize – Track the Progress

• Letter of Intent – Sell the “Why” – Clinic Locations – Roster of Billable Clinic Staff – Clinic Agency Letterhead

11

Payer Contracting

12

Negotiate Rates

Reimbursement Rate Updates Timeline

Contract Language Document Review

Effective Date Definition Implement the Contract!