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2012 Model Practice Application (Public)Application Name: 2012 Model Practice Application (Public) : Florida Department of Health in Volusia County : Secondary Review Process Applicant Name: Mrs. Kristie Johnson Application Title: Secondary Review Process Please enter email addresses you would like your confirmation to be sent to. kristie_johnson@doh.state.fl.us; Mary_Garcia2@doh.state.fl.us Practice Title Second Review Maximizing Revenue Submitting LHD/Agency/Organization Volusia County Health Department Head of LHD/Agency/Organization Dr. Bonita Sorensen Street Address 1845 Holsenback Drive Practice Contact Person Mary L. Garcia Title Financial Adminstrator Mary_Garcia2@doh.state.fl.us Submitting LHD/Agency/Organization Web Address (if applicable) www.volusiahealth.com Provide a brief summary of the practice in this section. This overview will be used to introduce the model or promising practice in the Model Practices Database. Although this section is not judged, the judges use it to get an overall idea about your practice. You must include answers to the following questions in your response:
• Size of population in your health department’s jurisdiction
• Who is your target population/audience, for this practice
• Size of target population/audience, if applicable
• The number or percentage of the target population/audience reached, if applicable
• Describe the nature and gravity of the public health issue addressed
• List the goal’s and objective(s) of the practice and clearly link them to the problem or issue the practice is addressing. Briefly indicate what the practice intends to accomplish overall.
• When (month and year) the practice was implemented.
• Briefly describe how the practice was implemented, what were major activities, and any start-up and in-kind costs and funding services.
• Outcomes of practice (list process milestones and intended/actual outcomes and impacts.
• Were all of the objectives met?
• What specific factors led to the success of this practice?
• Lessons learned from the practice The Volusia County Health Department (“VCHD”) is a governmental subdivision of the Florida Department of Health (“FDOH”), one of 67 county partnerships between the State and County governments to provide health services to the people of Florida. The State of Florida has a number of performance standards and processes that require and define such 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”).
Volusia County, Florida has an approximate population of 494,593 residents. Volusia County Health Department serves as the safety net for residents who do not have a medical home and as a leader in the community for public health issues. Volusia County Health Department's clinical program consists of four medical offices and two Dental offices located throughout our county. We also provide outreach services in both dental and medical within our community.
The team recognized a significant trend in the increased number of clients without a payor source. They formed a hypothesis that a "second review" would disclose services that would become billable to Medicaid retroactively for newly eligible Medicaid recipients. Florida Medicaid allows billing for services for up to twelve months from the date of service.
To provide quantitative proof-of-concept evidence, the existing local process was changed effective July, 2010. 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.
Overflow: Please finish the response to the question above by using this text area. Please be mindful of the word limits. na Describe the public health issue that this practice addresses. (350 word limit)
Florida county health departments have experienced reductions in funding over the past three years. By introducing this "second review" process, the team has demonstrated a methodology that will enhance revenues and preserve the ability to serve clients who are at or near the federal poverty level and have no payor source. What process was used to determine the relevancy of the public health issue to the community? (350 word limit) A review of Client superbills that where at or below federal poverity level.
How does the practice address the issue? 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. Identifying services for which Medicaid retroactive billing may be made enables the county health department to continue or offer services to other clients unable to pay.
Is the practice new to the field of public health? If so, answer the following questions. What process was used to determine that the practice is new to the field of public health? Please provide any supporting evidence you may have, e.g. literature review. The business office had a new administrator and billing supervisor. A review of all our processes and of all critical accounts receivable measures were begun as a part of the transition. One area was to improve the denial rate from insurance carriers. We noted that there were common errors that began at the provider level and flowed to the cashiers who input the data into our Practice Management System (HMS). This system is used by 67 local county health departments (CHD). HMS has a report that shows services not billed to Medicaid. The downfall is that the report is only useful if the clients are on Medicaid and currently receiving services. In addition, this report only shows Medicaid, not all insurances.
A process sprang up in-house to review and capture all encounter form errors, develop training of providers and cashiers and improve our billing processes. Volusia CHD uses an encounter form or “Superbill”. We performed a historical audit of superbill that were less than twelve months old for accuracy and to ensure that services were entered and billed. A surprising benefit of the process emerged where clients that had been at or below the Florida poverty level now had Medicaid or other insurance coverage. If insurance was now in effect, then services were billed.
How does this practice differ from other approaches used to address the public health issue? This practice looks at all clients that had no payor source over the course a year. It is unusual to have this type of a review once services are captured. In many cases the encounter forms are filed away and not looked at again. This process systematically reviews these encounter forms and researches to see is any of the clients received insurance coverage after services where rendered. For example, a client may have only come in once for services. If they received Medicaid coverage at a later date, in the past, nothing would trigger a review of the encounter. These services would not be picked up on the unbilled report because no insurance would have been listed for the client in to HMS.
Today other CHDs use the standard Medicaid log in HMS. There is no automated report, as there is nothing to trigger the change in the client status and the systems do not “talk to each other”. This practice is manual, so it has not been used by others. It can be easily replicated, and being able to capture revenue that otherwise would have been lost was a very pleasant surprise to us as well.
Is the practice a creative use of an existing tool or practice? If so, answer the following questions. No What tool or practice (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, etc.); did you use in a creative way to create your practice? (if applicable) (300 word limit total)
a. Is it in NACCHO’s Toolbox; (if not, have you uploaded it in the Toolbox)?
b. If you used a tool or practice to implement your practice, how was your approach to implementing the tool unique and innovative for your target area/population?
What process was used to determine that the practice is a creative use of an existing tool or practice? Please provide any supporting evidence you may have, for example, literature review. How does this practice differ from other approaches used to address the public health issue? Who were the primary stakeholders in the practice? Volusia County Health Department Business Office What is the LHD's role in this practice? As a governmental subdivision of the Florida Department of Health, the VCHD strives to be a leader in advocacy for public health, and coordinates its efforts with more than a dozen health-related providers (for-profit, governmental or non-profit, locally to nationally) that have an interest in the health of the residents and visitors to Volusia County. 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.
What is the role of stakeholders/partners in the planning and implementation of the practice? 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.
What does the LHD do to foster collaboration with community shareholders? Describe the relationship(s) and how it furthers the practice's goals. n/a Describe lessons learned and barriers to developing collaborations This project has provided convincing financial proof of concept to a procedure change that can be used by other county health department billing operations to generate additional revenue from Medicaid for services provided to clients prior to their determination of eligibility by Medicaid. 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. Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improves practice.
Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
List up to three primary objectives for the practice. For each objective, provide the following information: (750 word limit per objective)
Maximize the revenue from Medicaid and other third party insurances.
Increase or maintain services for client that are uninsured or underinsured.
• Performance measures used to evaluate the practice: List the performance measures used in your evaluation. Depending on the type of evaluation conducted, these might be measures of processes (e.g., number of meetings held, number of partners contacted), program outputs (e.g., number of clients served, number of informational flyers distributed), or program outcomes (e.g., policy change, change in knowledge or attitude, change in a health indicator)
• Data: List secondary and primary data sources used for the evaluation. Describe what primary data, if any were collected for each performance measure, who collected them, and how.
• Evaluation results: Summarize what the LHD learned from the process and/or outcome evaluation. To what extent did the LHD successfully implement the activities that supported that objective? To what extent was the objective achieved?
• Feedback: List who received the evaluation results, what lessons were learned, and what modifications, if any, were made to the practice as a result of the data findings.
1. Maximize the revenue from Medicaid and other third party insurances.
Medicaid is the payor source for a large portion of the services delivered each year. 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.
During the project, the Volusia County Health Department provided over 250,000 services in fiscal year 2010-2011. 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.
A spreadsheet was maintained to track these 1,280 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. For fiscal year 2010-2011 the log was totaled, yielding an actual net amount of additional revenue. This "second review" process generated $91,637.20 in additional revenue for previously provided services during fiscal year 2010-2011.
This team has provided convincing financial proof of concept to a procedure change that can be used by other county health department billing operations to generate additional revenue from Medicaid for services provided to clients prior to their determination of eligibility by Medicaid. 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.
Overflow (Objective 1): Please finish the response to the question above by using this text area. Please be mindful of the word limits. 2. Increase or maintain services for client that are uninsured or underinsured.
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. 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 $91,637.20 in additional revenue for previously provided services during fiscal year 2010-2011. Currently, these funds support major direct client health center operations throughout Volusia County. We estimate that this could equate to 509 additional visits per year. This allows the Volusia County Health Department to continue to be a safety net in our community. In the present economic climate, the Volusia County Health Department has sustained the level of services offered to the residents of Volusia County.
It is interesting to note that 293 of the encounters originally were billed to clients on a sliding fee scale (Federal Poverty Guidelines) in the amount of $15,882.40. According to Department of Health Accounts Receivable Policy, these 293 accounts could have gone to collections. The “second review” enabled the Volusia County Health Department to free the clients from this liability.
Overflow (Objective 2): Please finish the response to the question above by using this text area. Please be mindful of the word limits. Overflow (Objective 3): Please finish the response to the question above by using this text area. Please be mindful of the word limits. What are the specific tasks taken that achieve each goal and objective of the practice? A spreadsheet was maintained to track these 1,280 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. For fiscal year 2010-2011 the log was totaled, yielding an actual net amount of additional revenue. What was the timeframe for carrying out these tasks? This is still an ongoing process to continue maximizing the funding sources. Is there sufficient stakeholder commitment to sustain the practice? Describe how this commitment is ensured. The Volusia County Health Department billing unit had a new employee, a retiring employee, a new Billing Supervisor, and was short-staffed during this turnover period. To implement this policy and procedure change during this transition was a risk, and an obstacle to overcome. With current staffing, VCHD will be able to continue the process. Describe plans to sustain the practice over time and leverage resources. Many county health departments have had budget reductions. The Volusia County Health Department experienced a ten percent reduction in state funding. The agency is commented to maintaining the current staffing levels in order to continue this process. Practice Category Choice 1: Practice Category Choice 1, Part 2: Quality Improvement Practice Category Choice 2: Practice Category Choice 2, Part 2: Organizational Practices Practice Category Choice 3: Access to and/or Equality of Care Practice Category Choice 3, Part 2 Check all that apply. Colleague in my health department NACCHO Web Site |
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