Episode 5: Billing is Thrilling – Podcast Transcript

Abby Rose Esposito, Marketing Specialist (00:04):

Hello and welcome back to The MediSked Podcast. Today we will be chatting with MediSked Billing and EDI Analyst Kristy Love to answer your questions about healthcare billing. So Kristy, thank you so much for being here. Why don’t you tell us about yourself? How long have you been working in this field?

Kristy Love, Billing & EDI Analyst (00:23):

Hi, Abby Rose. I have been at MediSked for almost four years and I have been in the billing industry for about nine.

Abby Rose Esposito, Marketing Specialist (00:32):

Awesome. Well, we’re lucky to have you, what exactly is your role at MediSked and in what ways do you work directly with clients?

Kristy Love, Billing & EDI Analyst (00:40):

Yeah, soI am the Billing and EDI Analyst now. So I specialize in the computer software that we have at MediSked under HIPAA and EDI compliance. Typically the billing implementations for new agencies and clients. I work with the payers and the agencies directly for interface configuration, coding, and keeping up to date on any billing regulations and standards and changes.

Abby Rose Esposito, Marketing Specialist (01:07):

Very cool. So we asked people on social media what questions they have for you. So thanks to everyone who submitted one and we’ll get into those now. So first up, why do some services require Electronic Visit Verification (or EVV) before billing?

Kristy Love, Billing & EDI Analyst (01:23):

That’s a great question. The 21st Century Cures Act did come out in 2019 and there are requirements for EVV for specific services. Regardless of the program, if there are services that are Medicaid funded, personal care services or health home care services that begin and end in the home or community that is under EVV. So EVV is using technology to verify that these services were rendered to these individuals, making sure that Medicaid payments aren’t overpaid, basically the purpose of EVV is ensuring that no Medicaid is getting overpaid. And this all stems for vendors that are using technology to clock in and out for the home and community based services. A few things that are needed once these services are rendered would be the type of service that was performed, individual receiving the service, location of service, the individual providing the service, and also the time in and out.

Abby Rose Esposito, Marketing Specialist (02:30):

Awesome. That was a great overview of EVV. So thank you. Another question that we got, what is the difference between billing directly to Medicaid versus billing to a Medicaid managed care organization?

Kristy Love, Billing & EDI Analyst (02:45):

Yes. So under the fee for service model states pay providers directly for each covered service that a Medicaid beneficiary received and undermanaged care, the states pay a fee to the managed care plan for each person enrolled in the plan. So the way that this works typically is states will pay the Medicaid managed care organizations, a set amount per member per month payment for Medicaid services that are designed under any contract. So under federal law, the MCOs must be actually sound, which simply means that the, the rates are projected to provide, they have to be reasonable, appropriate attainable, and these are all done on a state level. So here in New York, ours are different, say, than down in North Carolina, where we are working with them now on their transitions and the unlike fee for service, there is definitely an upfront fixed payment for the plans.

Kristy Love, Billing & EDI Analyst (03:50):

Instead of the fee for service states can use a variety of like mechanisms to also project what rates there should be, any incentivize plans for performance ensuring payments wouldn’t be too high, too low because at the end of the day, they need to understand any like loss ratios. And also like these agencies and MCOs do also need to make money as well. And there are more than 39 or I think 30 MCO states, but there are some big names that like we know for MCOs like United health groups Centene, Anthem, Molina, Aetna, WellCare, and there’s a bunch more too.

Abby Rose Esposito, Marketing Specialist (04:32):

Got it. I think that definitely answered that question. Medicaid can be tricky to understand, to say the least. So that was definitely helpful. So what should HCBS organizations look for in a software provider in terms of billing automation?

Kristy Love, Billing & EDI Analyst (04:48):

Yeah. So this is definitely what we like to call our bread and butter here at MediSked. When they’re looking for a software provider, a lot of agencies that we run into, they are — more provider agencies, that is — either are keying things into a portal or they’re exporting Excel sheets. So the one main thing that I like to recognize here is that like everything we like to call automated in MediSked. So if a care manager or case managers in the system, and they just complete a block that they perform with an individual, it’s very quick to be complete, send to audit. And with one click, it gets submitted to billing. So we make that 837, it gets sent off to the payer. We get acknowledgment of the claim. We get any pre-adjudication edits. If there are any, if anything was rejected, then we can typically see payment immediately, if it’s going to state Medicaid, we can log in or the 835 process for the remittance. We also automate those. They come back into the system and the claims are automatically reconciled. So we can see any CRMs if there are any — claim reference members, that is — if anything needs to be adjusted or voided, you can see underpayment overpayment when there are rate changes for any HCBS services that can be backtracked. So if we’re billing out a hundred dollars, cause that’s the rate, but next week is 125, we always can automate the price that is sent out in a correct date within services. So the amount of billing intricacies that Connect can handle is very, very broad. The automation for 835s with not only Medicaid, but also any Excellus, Molina, like we were talking about before, we can bill any payer, which is huge for us and agencies.

Abby Rose Esposito, Marketing Specialist (06:50):

Awesome. Yeah. I know automation is huge for organizations in the HCBS world because of how much time it can save billing staff at agencies, especially in the middle of a workforce crisis and agencies with very limited funding for staffing. So as a billing expert, you are involved in testing claims and putting checks in place to ensure that claims are clean. So what should HCBS organizations keep in mind to ensure that all claims?

Kristy Love, Billing & EDI Analyst (07:20):

Yes. So back to the way that the system is set up, if there are certain regulations for a timeframe around services for what can be billed and what can’t be billed service settings can get complex, but to the point where if something cannot be billed until it was rendered for two hours. So if you’re in there and you complete a block for an hour and a half the block and the documentation of everything that happened will be there, which is great. It just doesn’t get pushed to billing because technically it’s a non-billable claim. If it crosses over a certain billing threshold that you have set in the system, the claims will get generated once the block is completed and then get sent out, there are definitely guardrails to keep claims compliant, any service overlap, because it is very common for individuals to receive multiple services within a day. So we just wanna make sure that nothing is getting overbilled or underbilled. And that’s partially why EVV also did come into effect here. So the service overlap and ensuring that any worker is not either double booked or any individual is not double booked. When these blocks are completed, is something else that we like to keep an eye on. So for provider agencies, the 837s, 835s, 277s, 270. So that’s claim status, eligibility files going out files coming in for payment. We do on both ends.

Abby Rose Esposito, Marketing Specialist (08:52):

Right. So we’ve been talking a lot about billing for provider agencies, but what about care management organizations like payers or government oversight agencies? I know MediSked works with care coordination organizations (or CCOs) in New York. As well as other care management entities nationwide, what does billing look like for them?

Kristy Love, Billing & EDI Analyst (09:12):

The billing and eligibility and remit for the CCOs currently is automated. The number is crazy. The amount of dollar amount of claims that we have built out since 2018 is like 1.7 billion, like with a B like crazy <laugh> Kansas, right now we are doing their two seventies and eligibility checks and it is on my radar that they potentially also would like to bill out of their coordinate platform.

Abby Rose Esposito, Marketing Specialist (09:41):

That’s one of the Kansas county developmental disability organizations, CDDOs.

Kristy Love, Billing & EDI Analyst (09:47):

Yes. And getting ready to ramp this up for North Carolina too.

Abby Rose Esposito, Marketing Specialist (09:52):

Great. Well, do you have any other tidbits of wisdom to share with our listeners before you part?

Kristy Love, Billing & EDI Analyst (09:57):

I definitely like to assure people that billing is not as scary or intimidating as most people think. Cause I think people get in the system and they’re always afraid to like get into the billing tab or learn more. So what I always tell my coworkers at MediSked is billing is thrilling. It definitely keeps the systems going. And the great part about billing that I think is like, there’s different things going on all the time, different challenges. So we’re always here to help any agency, any coworker, anyone’s learning anything new or wants to know more I’m always available.

Abby Rose Esposito, Marketing Specialist (10:37):

Billing is thrilling. Awesome. Well, thank you again so much Kristy for being here. We really appreciate it. If anyone has any questions, be sure to reach out to us and we will be happy to answer them. So see you soon Kristy!

Kristy Love, Billing & EDI Analyst (10:53):

Thank you so much.