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Billing better in CalAIM: how to improve reimbursement for enhanced care management and community supports
Billing better in CalAIM: how to improve reimbursement for enhanced care management and community supports
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Issue brief (California HealthCare Foundation)
- Author(s):
- Pagel, Lucy, author
Kane, Kathleen, (Of Aurrera Health Group), author
Mendoza-Nguyen, Kristin, author
Block, Lauren, (Of Aurrera Health Group), author
Donnelly, Jill, (Of Aurrera Health Group), author - Contributor(s):
- California HealthCare Foundation, issuing body.
- Publication:
- [Oakland, CA] : California Health Care Foundation, February 2023
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Administrative Claims, Healthcare
Costs and Cost Analysis
Fees and Charges
Health Expenditures
Insurance Claim Reporting
Medicaid
State Health Plans
California - Genre(s):
- Technical Report
- Abstract:
- CalAIM (California Advancing and Innovating Medi-Cal), which launched in 2022, is a multiyear initiative led by the California Department of Health Care Services (DHCS) to transform service delivery and improve outcomes for Californians covered under Medi-Cal. Enhanced Care Management (ECM) and Community Supports are core components of CalAIM that take a person-centered approach to social service delivery and care management for individuals with complex health and social needs. These services also require significant coordination between community-based organizations (CBOs), local and county entities, and Medi-Cal managed care plans (MCPs). The nature of Medi-Cal managed care billing, which requires confirmation of beneficiary enrollment in an MCP, authorization from the MCP, submission of claims or invoices, and tracking and correcting errors on claims or invoices before payment, results in complex billing protocols. Navigating this complex process is a barrier to entry for new providers and poses ongoing challenges for many existing contracted ECM and Community Supports providers. Integration of CBOs and other local entities new to Medi-Cal managed care is essential to providing ECM and Community Supports services, yet many lack the resources, experience, and capacity needed to successfully bill for the services that they provide. For some providers, billing challenges have resulted in a significant number of unpaid claims. Some have waited six or more months to receive payment, and many have reported receiving payments for few claims submitted during the first 10 months since the launch of CalAIM. For smaller providers, the lag between submission of claims and invoices and receipt of payment can create cash flow challenges and result in providers opting out of ECM and Community Supports. To better understand the situation facing ECM and Community Supports providers and identify potential solutions, Aurrera Health Group, with support from the California Health Care Foundation, conducted a series of stakeholder interviews with health plan representatives, county providers, CBOs, and MCP and provider associations (see Appendix A for a list of the interviewees). This issue brief outlines key challenges with each step of the billing process and technological and process-oriented recommendations for addressing them. Recommendations reflect potential strategies that could be implemented by DHCS, MCPs, and providers in the current delivery system, with the understanding that increased workforce, financing, and other resources are essential to improving the billing process.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. (More information)
- Extent:
- 1 online resource (1 PDF file (9 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 9918645975306676 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/9918645975306676