Billables Program Plan

ATTACHMENT – C: Billables Program Outline

Billing Program Plan

Outline

Background

• Provide a brief statement as to why your state would like to have public health clinics bill for immunization services.

• List the services (include immunization, if applicable) do your public health clinics currently bill for.

  • Include the percent that currently bill for immunization services if known.

  • If there are any billing systems in place for services other than immunization, how difficult/would it be possible to add an immunization component?

• Provide a brief statement of how your vaccine program operates. Be somewhat specific as this may impact assessments of how and where it could be implemented in the future.

• Outline the population breakdown in your state: (Include the following data if available)

  • % of population seeking immunization services from the public health clinics

  • % of clients seen in public health clinics who are Un-insured and Under-insured

  • % of clients seen in the public health clinics who are covered by Medicaid? Medicare? Private Insurance?

  • Provide any other breakdown that may be important.

Planning Process

• List your stakeholders:

• Indicate why each stakeholder was selected.

• List any stakeholders you could not get to the table but wanted to.

• List stakeholders that you should have included but did not.

• Describe the responsiveness of your stakeholders to the concept of planning an Immunization billing program for public health clinics in your state.

• Describe the process used to determine the capacity for public health clinics to bill for immunization services?

• List any state regulations that may support, hinder, or prohibit public health clinics from billing private insurance.

  • Identify any changes or new regulations that may be necessary to facilitate this billing process in your state.

• States have different profiles of payers and insurance plans.  Describe the landscape of payers in your state and how you went about discovering this.

• Describe patient information that must be collected to effectively bill 3^rd party insurance. Outline any changes necessary to facilitate the collection of this information. (include personnel training, processes, forms, technology, etc.)

• If applicable, describe the process already in place for submitting claims. Discuss what changes, if any, will be required to ensure that claims are properly submitted and ultimately paid. The process may vary among the different payers with possible need for agreements or contracts.

• Describe any agreements (if any) that have to be made with entities or organizations, other than payers, to complete this project.

• Identify barriers encountered to billing and describe what steps were taken, or should be taken, to address them.

• Develop a glossary of terms commonly used in conducting business with insurers.

Assessment of Readiness for Implementation

• Describe what evaluation or testing took place to show that the proposed process for billing third party payers will work, or will not work. Based on the analysis you should be able to provide answers to the following questions:

• What is the estimated percent of claims submitted to private insurance companies do you expect to be paid? ___________

• What is an estimate of potential revenue generated if billing is implemented statewide?

• What marker would you use to determine if implementation of a billing program at a specific health department or public health clinic would result beneficial and worth pursuing? (e.g.; number of insured patients).

• Consider the use of a billing clearing house or medical billing company. Will this be a viable option for your state? Why or Why not?

• What potential benefits will come from the revenue collected from billing?

• What barriers or downside to implementation of this program statewide may still exist?

• If you used pilot testing as a means to assess readiness for implementation of a billing program, discuss sites chosen and any significant findings you discovered.

Implementation

• Discuss the cost, program changes, or resources would be necessary to implement now or provide a timeline when you believe full implementation would be possible.

• How long would it take for this program to produce enough revenue to support its existence?