Medicaid Billing Hassles Pile up as Affordable Care Act Looms

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A host of localized Medicaid billing issues identified throughout the country—from intra-state repayment concerns to 5010 compliance issues—have the healthcare industry bracing for impact before the 2014 Affordable Care Act implementation deadline.

Kip Piper, a policy expert with the Sellers Dorsey consulting firm of Washington, DC, says it’s not unusual for state agencies “to encounter a ‘shake-down’ period to fix new systems” as billing vendors ramp up to the new instructions; yet “it’s easier for billing services to blame the state.”

“Developing and installing new Medicaid claims and enrollment systems is an inherently high-risk endeavor,” Piper says.

In Florida, where 25 counties are petitioning Governor Rick Scott to veto a $300 million bill for disputed Medicaid payments, neither patient services nor provider reimbursements have been interrupted, says Michelle Dahnke, director of communications for the Florida Agency for Health Care Administration.

But as the state seeks to recoup that money from within, she says, the question of who will ultimately pay the bill is a growing wedge issue.

“In Florida, the county governments have a statutory mandate to pay a certain portion of the state share for Medicaid recipients,” Dahnke says; historically, about 90%.

“Following the change in the Agency’s system in 2008, the counties (as a whole) have been denying to pay the state a significantly greater portion,” she says.

Piper says problems like those seen in Florida will worsen as Medicaid enrollment blooms by 24 million participants in 2014, eventually approaching 100 million by 2020. The changes required to comply with the new law and adapt to patient loads will place “enormous pressure” on eligibility and claims processing, he says.

Bill Gilbert, vice-president of marketing for AdvantEdge Healthcare Solutions (AHS) of Warren, NJ says that in addition to spiking patient loads, 5010 compliance issues are also slowing Medicaid payments.

“Clearly there were some Medicaid payers who weren’t ready for 5010 like they should have been,” Gilbert says. “They’re doing things like taking 5010 in and requiring the clearinghouse to convert 5010 to 4010 for them, and then the clearinghouse has to convert it back.”

Although these billing issues may be localized—and mitigated—for now, Gilbert says, it’s an area of concern that receives daily attention at AHS.

“The good news is that as a percentage of what’s been going on for our clients, including the imaging clients, [Medicaid] hasn’t had a dramatic impact on revenue,” he says.