1. Accounts Receivable: Timing of Clinical Billing Reimbursement for a Local Health Department J. Mac McCullough, PhD, MPH Maricopa County Department of Public Health Arizona State University

2. Acknowledgements  Co-author: William Riley, PhD Professor School for the Science of Health Care Delivery Arizona State University  Findings do not necessarily reflect the official position(s) of MCDPH.

3. Background: Vaccines & Prevention  Vaccination has prevented –322 million illnesses –21 million hospitalizations –732,000 premature deaths  Net cost savings –$295 billion direct costs –$1.38 trillion societal costs  Vaccines are one of the premier public health success stories. They’re highly cost effective.  But they aren’t free.

4. Vaccine Delivery & Financing  In some states (including AZ), state statute requires counties to assure vaccinations are available at no cost. –Yet no state funding is given to LHDs for vaccinations  How to assure the public health vaccine safety net remains in place? –LHD billing for vaccine product or administration  The details may vary, but this is likely a story broadly familiar to many. 4

5. Medical Billing Background  In private practice, clinical billing is a complex, professionalized undertaking. –Thousands of employers and employees, national associations, annual conferences.  A number of financial metrics are used to evaluate financial health and billing processes –It should be no different for health departments.  The purpose of this presentation is: –to present data from one county’s experiences billing for vaccines –motivation for establishing a set of financial metrics for use by public health department billing efforts. 5

6. Methods: Setting  MCDPH: serves Phoenix metro area (4 million)  3 Clinics: staffed by 8 Nurses and 3 desk clerks Roosevelt East Valley West Valley 6

7. Design & Data  Retrospective analysis of billing receipts. –Have billed Medicaid for years –Began billing private payers in 2012  Analyzed reimbursements received from Jan 2013 – Jun 2014. –73,931 transactions –61,250 unique immunizations –29,374 unique encounters  Small qualitative data component: –Meet with billing staff to understand workflow, estimate time from service delivery to submission of bill. 7

8.  For Uninsured: –Obtain vaccine product for free through federal grant program(s)  For Medicaid: –Obtain vaccine product for free through federal grant program(s) –Bill for administration of each shot (rates set by statute)  For private insured: –Purchase vaccine –Bill for vaccines according to negotiated rates Client Insurance Status & Vaccine Billing Note: As standalone clinic, MCDPH can only bill for the vaccines. There is no opportunity to bill for an office visit or any other services.

9. Analysis  Outcomes of interest: –Time to Reimbursement was calculated as the number of days between date of service and date(s) of reimbursement.  Additional stratified analyses separated Medicaid versus private payers 9

10. Findings  Reimbursements were received after a median of 68 days (range: 12 – 2,350).  Reimbursements (i.e., debits) were sometimes followed by take-backs (i.e., credits). –3.4% of transactions were credits. –Credit transactions occurred a median of 333 days from date of service. 10

11. Time to Reimbursement 11 Daily Revenue (percent of total, green line) Cumulative total (blue line)

12. Time to Reimbursement: Medicaid vs. Private Payers 12 Percent of total revenue received

13. Time to Bill Submission  On average, it took about 30 days from service delivery to bill submission. –After visit, MCDPH desk staff compiled paper forms, updated electronic immunization registry, completed paper forms. –Paper forms assembled, sent to central billing office. –Billing office enters into e-billing system, verifies info, sends to relevant payer. 13

14. Conclusion  A non-trivial lag exists between service provision and receipt of reimbursement. –One LHD’s billing efforts received ~80% of total reimbursement before the end of a fiscal year. –We found no difference in time to reimbursement for Medicaid versus private payers. –Small take backs will likely stretch for years after the visit. 14

15. Implications  As governmental entities, LHDs budget processes may not align with a 3++ month lag. –May necessitate special consideration in budgetary processes for services that receive clinical billing revenues. –Must look at all available opportunities to streamline billing processes  Clinical billing can be a million-dollar enterprise. –Many hospitals and provider groups have well developed metrics for accounts receivable. –Application of best practices (and metrics) from medical billing may help avoid unnecessary delays and/or improve billing processes. 15

16. Thank You! Questions? Mac McCullough mccullough@asu.edu