The Illinois Public Health Association (IPHA) has a successful five-year history in third-party billing capacity-building, credentialing and contracting, and billing and coding with local health departments, community-based organizations, and other healthcare providers throughout Illinois for immunizations, HIV testing, and other preventive health services.
In 2012, IPHA began a partnership with the Illinois Department of Public Health (IDPH) to provide administrative and program services for a four-year Immunization Billing Grant offered through the Centers for Disease Control and Prevention (CDC). The purpose of the grant was to enhance the capacity of local health departments throughout Illinois to bill third-party payers for immunizations and other health services provided to insured patients.
In the first two years of the grant, IPHA assisted 10 local health departments, serving 16 counties within Illinois, to become credentialed and contracted in order to bill for immunizations and other health services administered to insured patients covered by Medicaid, Medicare, and major insurance carriers prominent within each site’s geographic area.
By 2016, 84 local health departments across Illinois had received third-party billing capacity-building services through the project and more than $5 million in new revenue was generated. Additionally, by 2016, the project made available – through a partnership with CDP, Inc. (a Romeoville, Illinois-based firm specializing in third-party billing and electronic medical records) – a complete revenue cycle management system that was integrated with electronic medical records (EMR). CDP’s ezEMRx is a certified stage 1 and 2 Meaningful Use/Public Health-ready Electronic Medical Records (EMR) solution that is integrated with a complete revenue cycle management system.
In 2016, IPHA also began a successful collaboration with IDPH, the Public Health Institute of Metropolitan Chicago, and CDP, Inc., to enhance the capacity of local health departments, community-based organizations, and other healthcare providers throughout Illinois to bill third-party payers for routine HIV testing services and to implement electronic medical record systems. With federal and state appropriations for HIV services becoming less certain – and with Illinois HIV providers experiencing daunting economic challenges with the state’s recent budget woes – IPHA saw a real need to assist providers with generating revenue (independent of grant dollars) to sustain these vital services.
Through 2017, IPHA’s HIV Third-Party Billing Project has assisted more than 20 local health departments, community-based organizations, and other healthcare providers statewide with implementing third-party billing for routine HIV testing and implementing electronic medical record systems.
Additionally, through 2017, the project has provided HIV third-party billing capacity-building services to more than 20 local health departments, community-based organizations, and other healthcare providers across Illinois through a dedicated HIV third-party billing e-mail address, statewide regional HIV billing meetings, two HIV billing best practice white papers, an online HIV billing training module, and a series of educational webinars highlighting credentialing and contracting, billing and coding for HIV services, electronic medical records/revenue cycle management, HIV confidentiality and security, and HIV testing best practices.
At the outset of IPHA’s work with local health departments, community-based organizations, and other healthcare providers in 2016 to implement third-party billing for HIV testing services, most of these institutions had no experience with billing for public health services and lacked the knowledge base for these practices. Through IPHA’s partnership with CDP, local health departments, community-based organizations, and other healthcare providers were assigned certified billing liaisons at CDP and IPHA that walked providers through the credentialing and contracting process, walked them through the EHR implementation process, and helped them realign their clinic staffing and clinic flows to accommodate insurance billing for HIV and STD clients. This professional experience through CDP and IPHA resulted in numerous HIV billing best practices on the project, including:
- To ensure insured clients will participate in third-party billing of HIV testing and other HIV services, health departments and other healthcare providers often require health plans to omit HIV language on claims and Explanation of Benefits (EOBs) for confidentiality purposes.
- While health departments and other healthcare providers have become accustomed to billing for lab draws for HIV testing, project staff have worked to encourage billing for HIV counseling, PrEP counseling, and other related HIV services.
- A key to expanding billing for HIV services at community-based organizations is to work with health plans to have them recognize non-licensed staff (peer staff) as billable providers.
In 2018, these best practices will assist IPHA and CDP in expanding HIV billing successes and practices to include new HIV prevention services. Likewise, IPHA and CDP have staff that are respected as experts in the HIV credentialing, contracting, and billing and coding fields.
Of the 38 grantees that received funding from the CDC Immunization Billables Project, IPHA was one of only six to be featured on the CDC website as an Immunization Billing Success Story https://www.cdc.gov/vaccines/programs/billables-project/success-stories.html#il.
Overall Project Goals
Assist local health departments, community-based organizations, and other healthcare providers with credentialing and contracting with Medicaid and/or Medicaid Managed Care Organizations for HIV services.
Assist local health departments, community-based organizations, and other healthcare providers to initiate Medicaid and commercial insurance billing of HIV testing services.
Assist local health departments, community-based organizations, and other healthcare providers to implement a revenue cycle management system and/or an electronic medical records (EMR) system for HIV services.
Provide local health departments, community-based organizations, and other healthcare providers comprehensive capacity-building resources – to include webinars, white papers, and best practice manuals – to build these organizations’ competency with HIV third-party billing processes and practices.
Capacity-Building E-Mail Address
In 2016, the project was expected to offer a capacity-building call center or e-mail address to local health departments (LHDs) and healthcare providers (HCPs) that would assist providers with any technical assistance inquiries and questions related to third-party billing for HIV services. Below is a discussion of the capacity-building assistance provided by IPHA and CDP/ezEMRx staff to meet these needs:
On September 29, IPHA announced a new service to help local health departments and healthcare providers with questions about third-party billing. LHDs and HCPs can send billing-related questions to the following email address: firstname.lastname@example.org. IPHA staff will research all questions and respond with an answer. The goal is to respond to each question within no more than two business days.
Stakeholder Advisory Group Meetings
As an accountability best practice from IPHA’s third-party billing projects, IPHA will convene quarterly meetings of a stakeholder advisory group (SAG) for the HIV Third-Party Billing Project that will provide capacity-building assistance and guidance to local health departments, community-based organizations, and other healthcare providers implementing HIV third-party billing. The SAG -- comprised of commercial insurers, healthcare providers, Medicaid staff, public health staff, EMR and billing specialists, and other interested parties – will help project sites build capacity, will share lessons learned, and will help guide the project.