Medi-Cal Paid Claims Reports Huh??? Joanne Roberts, PHN Perinatal Services Coordinator Los Angeles County November 14, 2013

Objectives Perinatal Services Coordinators will: Be able to interpret the information on the Medi-Cal Paid Claims Report Understand why the Paid Claims Report is an essential component of quality assurance and monitoring

What Is It? Report of claims paid by Medi-Cal for a 6-month period: Jan-June and July- Dec Fee-for-service only Does not include Medi-Cal Managed Care, FQHC, RHC, IHC

3 Separate Reports Delivery Only Non-Delivery Only CPSP Only

Non-Delivery & Delivery Only Non-Delivery: prenatal, postpartum, and global codes Delivery Only: deliveries (excluding global billing codes) Use to identify/recruit new CPSP providers

CPSP Report Health education, nutrition, and psychosocial services CPSP bonuses: early entry and 10 th visit Monitor CPSP provider activity

What’s in the CPSP Report? County Name Provider Type Code Provider Specialty Code Provider Legal Name Provider Address, City, Zip Code

What Does It Tell Me? Who’s billing CPSP in your county? –Do you recognize all the names? –Non-CPSP providers? –Approved providers missing? –Different address? –Approved providers with unknown sites?

What’s in the CPSP Report? “Claim Count” –Number of services “Total Billed Quantity” –Units of service Example: –Claim count (# of services) = 50 –Total billed quantity (# units) = 147

Claim Count & Quantity Compare the numbers Quantity usually 2-3 times more than Count When Count = Quantity –Only 1-unit services are billed –Usually means bonuses only –Could be billing error

Now for the Money! Does the total amount paid fit with the provider type? –Is small solo practice making $200,000 for CPSP only –Is large hospital clinic making only $10,000

Red Flags Providers reimbursed more than expected –Misunderstanding –Intentional overbilling (fraud) –CPSP done at multiple sites billed from one site (other sites may not be CPSP approved)

Red Flags Providers reimbursed less than expected –Misunderstanding by provider staff –Biller not billing correctly: “Medi-Cal doesn’t pay.”

Hospitals Lower than expected reimbursement? –Billing departments and clinic staff don’t communicate –Clinic staff may not mark correct # units –Billers submit as claims “Quantity = 1” for all services, regardless of # of units provided –Hospital computers programmed to discard any claim below a certain amount ($25, $50)

What Do I Do With It? Review prior to calling/visiting any fee-for- service provider Ask provider how billing is going? Compare response to paid claims amount

Example #1 PSC: Hi, I’m calling to schedule your annual CPSP quality assurance review. Office Manager: Oh, we’re not doing CPSP right now. PSC: Really, because the report I’m looking at shows that you billed $187,000 just for CPSP services between January and June of this year. Office Manager: That’s impossible!

Example #2 PSC: Hi, I’m calling to schedule your annual CPSP quality assurance review. How’s everything going? Are you billing for CPSP? Office Manager: Everything’s great! We’re seeing a lot of CPSP patients and the billing is fine. PSC: Are you sure because I have a report that shows you haven’t been reimbursed anything in the last 6 months. Office Manager: (silence)

Let’s Look at the Report Paid Claims Report Jan-Jun 2013 Volunteer needed!

Next Steps Update the billing codes used in the CPSP, Non-Delivery, and Delivery Only reports Rename the column labels to be more self-explanatory Continue relationship between MCAH and Medi-Cal to ensure uninterrupted availability of the Paid Claims Report

Conclusion Paid claims are invaluable to PSCs The report’s not that complicated once you know what you’re looking at

Billing Resources Medi-Cal: –Provider Manual, Bulletins, Learning Portal, contact Regional Representative ACS/Xerox (Medi-Cal Fiscal Intermediary) –Telephone Service Center (TSC): –To leave a message for a Regional Representative, call the TSC then follow the prompts 11, 15, 14 21

Thank you! Joanne Roberts, PHN (213)