FEBRUARY 2023 Issue Brief by Aurrera Health Group Billing Better in CalAIM: How to Improve Reimbursement for Enhanced Care Management and Community Supports C alAIM (California Advancing and Innovating submission of claims and invoices and receipt of Medi-Cal), which launched in 2022, is a multi- payment can create cash flow challenges and result year initiative led by the California Department in providers opting out of ECM and Community of Health Care Services (DHCS) to transform service Supports. delivery and improve outcomes for Californians cov- ered under Medi-Cal. Enhanced Care Management To better understand the situation facing ECM and (ECM) and Community Supports are core components Community Supports providers and identify potential of CalAIM that take a person-centered approach to solutions, Aurrera Health Group, with support from social service delivery and care management for indi- the California Health Care Foundation, conducted a viduals with complex health and social needs. These series of stakeholder interviews with health plan rep- services also require significant coordination between resentatives, county providers, CBOs, and MCP and community-based organizations (CBOs), local and provider associations (see Appendix A for a list of the county entities, and Medi-Cal managed care plans interviewees). This issue brief outlines key challenges (MCPs). The nature of Medi-Cal managed care billing, with each step of the billing process and techno- which requires confirmation of beneficiary enrollment logical and process-oriented recommendations for in an MCP, authorization from the MCP, submission of addressing them. Recommendations reflect poten- claims or invoices, and tracking and correcting errors tial strategies that could be implemented by DHCS, on claims or invoices before payment, results in com- MCPs, and providers in the current delivery system, plex billing protocols. Navigating this complex process with the understanding that increased workforce, is a barrier to entry for new providers and poses ongo- financing, and other resources are essential to improv- ing challenges for many existing contracted ECM and ing the billing process. Community Supports providers. Integration of CBOs and other local entities new to Medi-Cal managed care is essential to providing ECM and Community Billing and Revenue Cycle Supports services, yet many lack the resources, expe- Requirements rience, and capacity needed to successfully bill for the This brief identifies challenges that providers may services that they provide. face throughout the billing process and provides con- siderations for solutions. Figure 1 illustrates steps in For some providers, billing challenges have resulted the billing process from the identification of eligible in a significant number of unpaid claims. Some have clients to service delivery. For more key recommen- waited six or more months to receive payment, and dations on enrollment, eligibility, and authorizations, many have reported receiving payments for few claims see the section called Prior to Billing: Enrollment submitted during the first 10 months since the launch and Authorizations. Figure 2 outlines the process for of CalAIM. For smaller providers, the lag between claims submission through adjudication and payment, One-on-one support from billing experts to help highlighting areas of potential variability between the providers: MCPs and common reasons for claims denials. For $ Understand MCP requirements and processes more information, see the section called Preparing and Submitting Claims. and reconcile different processes between MCPs $ Develop internal billing processes Key Challenges and Recommenda- $ Train staff tions for Improving Billing Processes for ECM and Community Supports Information on clearinghouses and billing software, including: Providers $ List of clearinghouse vendors Overall Recommendations $ The role of clearinghouses and what billing- The overall message that interviewees shared is that related activities are in and out of the scope of the billing process is complicated and that it requires clearinghouse vendors many resources from both MCPs and providers to develop internal billing workflows, seek authorization, $ Cost expectations and payment models address denials, and, ultimately, reconcile payments for services delivered. Prior to Billing: Enrollment and Authorizations Interviewees included providers at the forefront of implementing ECM and Community Supports Verifying Medi-Cal managed care enrollment in advance of additional technical assistance and Providers must verify that their clients are enrolled with resources offered through the state's Providing Access a Medi-Cal MCP as the first step before delivering a and Transforming Health (PATH) Technical Assistance service to submit a claim (see Figure 1). However, some (TA) marketplace in 2023. PATH TA resources may be providers who verified enrollment reported claim deni- instrumental in setting up small providers for successful als due to a lag between the member's enrollment and billing by providing them with free technical assistance the MCP's receipt of up-to-date enrollment files. (i.e., PATH TA will be paid for through DHCS and is free to providers). Billing-related TA products and ser- Recommendation #1: Align claims submission time- vices providers would benefit from could include: line with MCP enrollment. Providers with experience in the Whole Person Care Pilots and Health Homes A billing guide targeted at CBOs that includes: Program shared that delaying their claims submission timeline by up to a month to align with the MCP's $ A detailed walk-through of generic billing work- receipt of enrollment data helps prevent denials due flows and expectations to data lags. Providers may work with MCPs to identify $ Coding guidance enrollment data cycles and align claims submissions accordingly. $ Frequently asked questions (FAQs) Validating eligibility for benefits or services For providers working with more than one MCP, vari- ability between MCPs' service eligibility criteria leads to confusion regarding which members are eligible for Community Supports and ECM (see Figure 1). California Health Care Foundation www.chcf.org 2 Figure 1: Preparing to Deliver ECM and/or Community Supports Services PREPARE TO DELIVER SERVICES Client engaged and agrees to receive Enhanced Care Management (ECM) or Community Supports. Is client enrolled in a Refer to enrollment counselor Medi-Cal Managed No to apply for Medi-Cal and/or Care Plan (MCP)? select and enroll in an MCP. Individuals must be enrolled in Medi-Cal Managed Care to be eligible for ECM and Community Supports. Yes Is client eligible for Refer to other services available ECM or No to meet client needs. Community Supports? Yes If needed, does client Request MCP makes Provider resubmits have an approved authorization Develop workflow authorization Not authorization with No to enable information authorization for ECM from MCP. exchange with MCP. decision. Authorized diagnosis information or and/or Community evidence of social needs Supports? to justify authorization. Authorized Confirm with MCPs: MCPs If provider has no other may provide presumptive information to provide, authorization for some authorization remains denied. services. Yes DELIVER Patient may appeal SERVICE determination. Recommendation #2: Outline standard eligibility diverse community settings rather than clinics or hos- criteria. MCPs may consider developing and dissemi- pitals (see Figure 1). nating consistent eligibility screening checklists or resources that providers can use to support or submit Recommendation #3: Align Community Supports with referrals. An ECM and/or Community Supports authorization parameters to model of care. MCPs eligibility screening checklist or resource can help out- can improve the authorization process by working line standard eligibility criteria for services. with Community Supports providers to integrate nuances of the Community Supports model of care Seeking authorizations delivery within existing referral and authorization sys- When seeking authorizations from MCPs, providers tems. For example, one MCP and a Medically Tailored reported that traditional authorization workflows do Meals/Medically Supportive Food provider worked not always map to the social service-based model of together to ensure billing processes and authori- care delivery required for certain Community Supports, zations accounted for a weekly delivery cadence, which are novel services that are often delivered in which decreased time-consuming claims denials and improved workflows for both parties. California Health Care Foundation www.chcf.org 3 Preparing and Submitting Claims "[Our county] wants to continue providing Understanding the process Enhanced Care Management, but senior All provider interviewees noted the need for hands- leadership may have to pull the plug on the on TA to address each step of the billing process, program because we haven't been paid for the from reviewing 837-P and CMS-1500 claims forms majority of the services we've provided since and acceptable submission modalities to navigating each MCP's billing portal and/or invoicing processes. January 2022." Providers noted that in addition to MCP-specific TA, -County ECM provider TA on billing basics (e.g., Billing 101) is needed to ensure that they understand all components of the Invoice and claims submission process and are well prepared for future audits. Providers that submit invoices instead of claims need instructions on invoicing formats and submission pro- Recommendation #4: Make one-on-one TA easily cesses. When procedures for submitting batched accessible. Some providers reported improved learn- invoice data are unclear or not available, providers ing when MCPs provided TA in a variety of formats, manually enter individual submissions, leading to such as webinars, reference guides, and one-on-one increased administrative burden and higher risk for TA. While asynchronous and easily referenced TA manual data entry errors. Additionally, it is standard offerings such as webinar recordings and tip sheets practice for MCPs to defer to providers regarding are helpful in building organizational knowledge, which billing codes to use based on their clinical one-on-one TA is also necessary for answering orga- expertise. However, small providers with less billing nization-specific questions. Providers that had close experience believe additional clarification around relationships with contacts from their MCP reported coding from the MCP would be helpful in decreasing that such access to a consistent point of contact denials (see Figure 2, next page). who could offer one-on-one TA was fundamental to successful program implementation and ongo- ing operations. While most MCPs provide some TA Test claim and invoicing submission and a contact person to support providers through systems and collaborate across MCPs to the billing process, MCPs are also new to ECM and standardize diagnosis codes Community Supports and may not always have the To reduce claims denials and increase clean claims capacity to connect each provider with someone who submissions, MCPs and providers should test claims can answer a provider's range of programmatic and and invoicing systems prior to service delivery and technical billing questions. As DHCS prepares to open collaborate to standardize the use of diagnosis and the PATH TA marketplace in early 2023, this provides billing codes to streamline workflows and improve claims processing. an opportunity for providers to access billing-specific TA resources, such as: 1) off-the-shelf billing guides, 2) information on billing software and clearinghouses, and 3) access to additional vendors offering one-on- Recommendation #5: Test systems before provid- one TA to help them establish effective, automated, ing services at scale. Providers and MCPs can run and audit-ready internal billing processes. tests with "dummy" claims and invoices and/or small batches of real claims prior to and during ramp-up of service delivery. CBO providers reported that when MCPs gave them the opportunity to submit test invoices after the contracting process and prior to California Health Care Foundation www.chcf.org 4 Figure 2: Submitting Claims and Receiving Payment PREPARE TO SUBMIT CLAIM Common reasons for Ensure you have everything you need to submit a claim: denial: Missing or incorrect information, • Client and provider information duplicate claims, and • Ensure date of service falls within the authorization effective member eligibility dates issues. Check claim SUBMIT CLAIM TO MCP OR VENDOR Timeframe for status and Submit claim directly to the MCP or to a contracted third-party provider claims address denial submission to MCP vendor, such as a claims clearinghouse. Standard formats: may vary by plan. codes. • Electronic submission • Paper mail Provider receives TRACK STATUS OF CLAIM Develop process to denial codes • Electronic: Review MCP billing or Care Management portal: track claims after describing the submission to verify ▪ Claims may pass through clearinghouse but can get whether billing is error(s). denied at the MCP. accepted or rejected. ▪ Tracking claims status via MCP billing or Care Management portal is recommended. *MCPs are required to pay 90% of all clean • Paper: Track print mail for health plan correspondence claims within 30 days, and 99% within 90 days. DENIED APPROVED Claim has all required information and is error-free. Get paid. *Department of Health Care Services managed care plan boilerplate contracts Exhibit A, Attachment 8, Section 5b. *Department of Health Care Services managed care plan boilerplate contracts Exhibit A, Attachment 8, Section 5b. https://www.dhcs.ca.gov/provgovpart/Documents/2-Plan-Non-CCI-Boilerplate-Final-Rule-Amendment.pdf https://www.dhcs.ca.gov/provgovpart/Documents/2-Plan-Non-CCI-Boilerplate-Final-Rule-Amendment.pdf service delivery, it helped prevent payment delays by potentially a cost-effective strategy for claims process- enabling MCPs and providers to identify and address ing for providers operating in counties with multiple portal navigation issues and fix submission errors MCPs whose submission processes and requirements before program go-lives. vary. They also can simplify the process of tracking errors and adhering to multiple submission formats for Claims management and tracking through third- providers with limited administrative capacity. More party vendors information on clearinghouse vendors and common Providers may leverage electronic health record (EHR) functions can be found in Appendix B. systems and third-party clearinghouses to stream- line billing and decrease administrative burden while Despite their interest in exploring the use of clearing- improving efficiency, quality, and consistency in claims houses, most providers lack the capacity to research submissions. EHRs enable providers to pull neces- appropriate vendors and vet their ability to inte- sary billing data automatically, rather than through a grate into MCPs' existing systems. Several providers manual process. Clearinghouses can streamline claims also noted that without sustainable funding streams, submission and serve as a validation step to support long-term contracting with clearinghouses may be a clean claims submission to MCPs. Clearinghouses are challenge. Many providers felt limited in their ability and bandwidth to research and evaluate potential vendors. California Health Care Foundation www.chcf.org 5 While some MCPs provide information about clear- can work with a clearinghouse through electronic inghouses or even free access to them for contracted data interchange (EDI), avoiding the need to use a providers, it is not a universal practice. One MCP portal. Contracting directly with a clearinghouse pro- noted that after several challenges with providers sub- vides real-time information to support billing, reduces mitting invoices, they began requiring providers to denial rates, creates a single workflow for the provider, use clearinghouses. and allows flexibility in staffing and hiring. In addition, many plans provide access to EDI through a clearing- Recommendation #6: Publish clearinghouse guid- house for free. The PATH TA marketplace may provide ance. Several interviewees suggested that MCPs or an opportunity for providers to obtain support in another organization (perhaps funded through PATH) researching and contracting with a clearinghouse, could help facilitate outreach to vendors and decrease and resources accessed through PATH's Capacity and their research burden by offering guidance about Infrastructure Transition, Expansion and Development which vendors would best be able to meet MCP bill- (CITED) initiative or from an MCP's incentive fund can ing requirements. A PATH TA vendor and/or MCPs help pay up-front costs. may consider developing provider-facing resources that list compliant clearinghouses that interface with MCP billing platforms, the process for contracting with Conclusion them, and their associated estimated costs. ECM and Community Supports offer innovative oppor- tunities for Medi-Cal to improve member experiences Tracking Submitted Claims and Managing by coordinating care and addressing member health Denials and Payment Delays and social needs. As new Medi-Cal providers face bar- riers to billing, all CalAIM stakeholders can play a role in Administrative capacity developing process-oriented and technological solu- Providers interviewed noted that they need more bill- tions that ensure smooth delivery of services through ing staff to manage claims submission and tracking. improved workflows and increased clarity, communi- For small providers, this presents a particular challenge cation, and technical assistance, while the PATH TA as many do not have the financial capacity to hire new marketplace offers an opportunity for new providers staff. Providers contracted with multiple MCPs face to access billing experts to help them address techni- increased workflow challenges and require additional cal and process-based billing challenges. resources to navigate each plan's billing processes (see Figure 2). Providers are hesitant to invest more resources into administrative capacity without assurances of sus- Recommendation #7: Lower barriers to using tainable funding and long-term contracts with the clearinghouses. As noted, clearinghouses can help MCPs to provide Community Supports. Because providers submit, track, and manage claims. Early Community Supports are optional for MCPs to offer, experience suggests that portals create inefficiencies providers are concerned that MCPs may decide to in multi-plan counties because the user experience stop offering these services, putting providers' invest- and workflow differ between plans. Where MCPs can ments into their programs at risk. As PATH funding coordinate to offer a single user experience, they can becomes more widely available in 2023, it will be create efficiencies for smaller providers and decrease important to track whether it results in enough fund- billing challenges. ing to help small providers develop service delivery and billing strategies that enable them to become If providers have an electronic billing system (e.g., long-term ECM and Community Supports providers. an EHR or practice management software), they also California Health Care Foundation www.chcf.org 6 About the Author Lucy Pagel, MPH; Kathleen Kane, MPH; Kristin Mendoza-Nguyen, MPH; Lauren Block, MPA; and Jill Donnelly, MPH, are consultants at Aurrera Health Group, a mission-driven national health policy and communications firm based in Sacramento. About the Foundation The California Health Care Foundation (CHCF) is dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient- centered health care system. California Health Care Foundation www.chcf.org 7 Appendix A. Interviewees Organization California Association of Health Plans Ceres Community Project County Behavioral Health Directors Association of California (CBHDA) and representatives from Alameda, Los Angeles, Nevada, Placer, Santa Clara, San Bernardino, Shasta, and Tulare counties Enhanced Care Management (ECM) providers from Marin, San Francisco, Santa Cruz, Placer, San Joaquin, Santa Clara, Riverside, and Shasta counties participating in the Whole Person Care Learning Collaborative El Sol Neighborhood Educational Center Kaiser Permanente Pamela Mokler & Associates, Inc. People Assisting the Homeless (PATH) Regional Asthma Management and Prevention California Health Care Foundation www.chcf.org 8 Appendix B. Clearinghouse Vendors and 2. Does the clearinghouse offer the following Common Service Offerings services? $ Claims submission tests Providers may leverage third-party vendors, such as claims clearinghouses, to streamline billing and $ Real-time client benefits and eligibility review decrease administrative burden while improving effi- $ Electronic claims review and submission ciency, quality, and consistency in claims submissions. Clearinghouses can offer providers a higher likelihood $ Electronic remittance advice (ERA) of submitting claims without errors and potentially $ Electronic funds transfer (EFT) receiving timely payments from managed care plans (MCPs). Furthermore, clearinghouses may be espe- cially useful for providers operating in counties with 3. Consider vendor costs and pricing structures if multiple MCPs with different requirements. your MCP does not offer a free clearinghouse. Common pricing structures include monthly fees, Providers considering contracting with a claims clear- fixed service transaction fees or transaction fees inghouse may consider the following questions to based on volume, or a percent of monthly revenue inform their decision: collections. 1. Check to see if the MCP(s) offers the use of a The list below identifies some commonly used claims clearinghouse for free or at no cost to contracted clearinghouses. This list is not comprehensive and providers. If no vendor is offered for free or at no there may be other vendors that may be able to meet cost, providers interested in using a claims clearing- provider and MCP needs and requirements. house should work with their MCP to identify any recommended clearinghouses that the MCPs' pro- vider networks currently use. Vendor Contact Payer List Ability (By https://www.inovalon.com/products/ https://www.abilitynetwork.com/payer-list/ Inovalon) provider-cloud/ Availity https://www.availity.com/ https://apps.availity.com/public-web/payerlist-ui/payerlist-ui/#/ Change https://www.changehealthcare.com/ https://payerfinder.changehealthcare.com/npd?adobe_mc=MCO Healthcare RGID%3D26CD3A665C7D19990A495D73%2540AdobeOrg%7CTS %3D1668642561 Conduent https://www.conduent.com/ https://downloads.conduent.com/content/usa/en/document/ edi-gateway-eligibility-payer-list.pdf Office Ally https://cms.officeally.com/ https://cms.officeally.com/Pages/ResourceCenter/PayerLists/ PayerList.aspx Optum https://www.optum.com/business/ https://iedi.optum.com/iedi/enspublic/Download/Payerlists/ Intelligent EDI health-plans/claims-payment-accuracy/ Medicalpayerlist.pdf edi-workflows.html The SSI Group https://thessigroup.com/ https://cws.ssigroup.com/payerlist/ California Health Care Foundation www.chcf.org 9