WIPHL Meetingon Promoting Sustainability

Through Billingand Tracking

Claims Experience

Friday, December 3, 12:00 to 12:30

Wednesday, December 9, 8:30 to 9:00

Wednesday December 9, 12:00 to 12:30

Sustainability =

•Provide sufficient numbers

of reimbursable services

•Submit claims

•Collect on claims

Sustainability =

•Provide sufficient numbers

of reimbursable services

•Submit claims

•Collect on claims

Recommendation: Expand to tobacco

•Leading cause of death in

Wisconsin

•Prevalence = 20%

•70% of smokers want to quit

QUIT RATES

Optimal Intervention

•Physician or non-physician

•>1 clinician

•31 to 300 minutes over >8 sessions

•Face-to-face counseling

•Combine with phone, group, or self-help

•Medications & counseling

•Address huge clinical need

•More individuals with alcohol problems die from their tobacco use than alcohol use

•Allow health educators to generate more reimbursement

Recommendation: Expand to tobacco

Why?

Sustainability =

•Provide sufficient numbers

of reimbursable services

•Submit claims

•Collect on claims

BillingPlan Tobacco Alcohol/drugs

Commercial99406

$15

Medicare99406

$14

99406 - >3 to 10 minutes • 99407 - >10 minutes

99406 - >3 to 10 minutes • 99407 - >10 minutes

Plan Tobacco Alcohol/drugs

Commercial99406

$1599407

$30

Medicare99406

$1499407

$29

Billing

Plan Tobacco Alcohol/drugs

Commercial

99406$15

99407$30

99408$33

Medicare99406$14

99407$29

G0396$30

99406 - >3 to 10 minutes • 99407 - >10 minutes

G0396/99408 - 15 to 30 min • G0397/99409 - >30 min

Billing

Plan Tobacco Alcohol/drugs

Commercial99406

$1599407

$3099408

$3399409

$66

Medicare99406

$1499407

$29G0396

$30G0397

$58

99406 - >3 to 10 minutes • 99407 - >10 minutes

G0396/99408 - 15 to 30 min • G0397/99409 - >30 min

Billing

Plan Tobacco Alcohol/drugs

Commercial99406

$1599407

$3099408

$3399409

$66

Medicare99406

$1499407

$29G0396

$30G0397

$58

99406 - >3 to 10 minutes • 99407 - >10 minutes

G0396/99408 - 15 to 30 min • G0397/99409 - >30 min

* HE services billable: place of service code 11 & no other provider

*

Billing

Plan Tobacco Alcohol/drugs

Commercial99406

$1599407

$3099408

$3399409

$66

Medicare99406

$1499407

$29G0396

$30G0397

$58

99406 - >3 to 10 minutes • 99407 - >10 minutes

G0396/99408 - 15 to 30 min • G0397/99409 - >30 min* HE services billable: place of service code 11 & no other provider

Medicaid99406

$1199407

$22

*

Billing

Plan Tobacco Alcohol/drugs

Commercial99406

$1599407

$3099408

$3399409

$66

Medicare99406

$1499407

$29G0396

$30G0397

$58

99406 - >3 to 10 minutes • 99407 - >10 minutes

G0396/99408 - 15 to 30 min • G0397/99409 - >30 min* HE services billable: place of service code 11 & no other provider

H0049 - full screen • H0050 - per 15 min intervention - up to 4/d

Medicaid99406$11

99407$22

H0049$35

*

Billing

Plan Tobacco Alcohol/drugs

Commercial99406

$1599407

$3099408

$3399409

$66

Medicare99406

$1499407

$29G0396

$30G0397

$58

99406 - >3 to 10 minutes • 99407 - >10 minutes

G0396/99408 - 15 to 30 min • G0397/99409 - >30 min* HE services billable: place of service code 11 & no other provider

H0049 - full screen • H0050 - per 15 min intervention - up to 4/d

Medicaid99406

$1199407

$22H0049

$35H0050

$20

*

Billing

Plan Tobacco Alcohol/drugs

Commercial99406

$1599407

$3099408

$3399409

$66

Medicare99406

$1499407

$29G0396

$30G0397

$58

99406 - >3 to 10 minutes • 99407 - >10 minutes

G0396/99408 - 15 to 30 min • G0397/99409 - >30 min* HE services billable: place of service code 11 & no other provider

H0049 - full screen • H0050 - per 15 min intervention - up to 4/d

Medicaid99406

$1199407

$22H0049

$35H0050

$20

*

Billing

Sustainability =

•Provide sufficient numbers

of reimbursable services

•Submit claims

•Collect on claims

Assumptions

•80% commercial, 20% Medicaid

•60% tobacco, 40% alcohol/drugs

•Medicaid tobacco and Commercial75% receive lower level service

•Medicaid alcohol/drugs - 50% bill for H0050

•Time spent

99406 - 5 min 99407 - 15 min

99408 - 20 min 99409 - 40 min

H0049 - 5 min H0050 - 20 min

Per Health Educator ...

# Reimbursed Services per Day

Contact Timeper Day

Revenue per Year

10 2.3 hours $71,370

15 3.4 hours $107,055

20 4.6 hours $142,740

WIPHL is Promoting“Effective Reimbursement”1. Reimburse under tobacco, alcohol and

drug billing codes

2. Reimburse when paraprofessionals deliver the services

3. Reimburse when paraprofessionals and credentialed providers deliver services at the same visit

4. No cost sharing with patients

WE NEED YOU TO

• Submit claims • Appeal denials • Keep us informed

SO WE CAN• Document which payers “effectively reimburse”• Advocate with payers who don’t

Claims Tracking System

•Retrospective entry - entire claim history

•Prospective entry

- Enter initial claim data

- Enter payer response> Paid satisfactorily > Paid unsatisfactorily> Declined > Declined due to error

- Enter site action> Close > Appeal

- Enter payer response to appeal

$4

$4

$4

$4

Database system designed by Steve Baillies

ClaimDataEntry Form

Data Submission Alternatives

•Enter claims directlyinto the database

•Electronically transferthe data to WIPHL –eg, Excel file

•Send/fax printouts fromyour billing system

(Covered by our business associate agreement)

Requests

•Site administration- Agree to help with this effort- Ask your billing staff to help

•Email Steve (steve.baillies@fammed.wisc.edu)with the name and contact information of your billing staff

•Complete and submit your quarterly report on unreimbursed expenses

•Start tobacco services

Thank you!Together we will make

tobacco, alcohol and drug screening and intervention sustainable in Wisconsin!