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Billing Project Success Stories

These awardees were persistent and creative in their efforts to develop billing programs in their areas. The success stories below describe how they met the challenges and overcame the barriers they faced.

Locations and Key Words

  • Arizona - billing, centralization, contracting, legislation, stakeholders
  • California (Kern County) - billing, coding, contracting, training, toolkit/manual
  • Georgia - billing, centralization, credentialing, coding, training, toolkit/manual
  • Illinois - billing, coding, contracts, HIPAA
  • Massachusetts - billing, clearinghouse, credentialing, contracting, decentralization, stakeholders
  • Nevada - billing, contracting, stakeholders, training

Arizona

Arizona's billing program is coordinated by the Arizona Partnership for Immunization (TAPI), a coalition that includes Arizona’s state and local health departments, as well as the state's provider organizations and other groups concerned with immunization issues.

TAPI has been working to build the state's billing program for five years. While the program was up and running before CDC's Billables Project began, it was the American Recovery and Reinvestment grant from CDC that infused funding and resources to put staffing and systems in place to allow for expansion and larger reimbursements from payers.

In the first three years of billing, the revenue generated from vaccine administration fees was used to hire two additional nurses, as well as a child care consultant to educate child care workers on immunization.

One of the keys to Arizona's success has been the centralization of its billing program, according to Jennifer Tinney, Program Director for TAPI. TAPI set up Arizona's billing office to serve the state and local health departments, providing much needed leverage that enabled the organization to put contracts in place to bill some of the state's largest private insurance payers. "We had a difficult time getting contracts with private health plans," says Tinney, adding that private insurance payers were resistant to bringing on public health entities as network providers. "It was important to have the leverage of the entire public health community instead of each county health department trying to bill on its own."

TAPI also used the power of legislation to acquire contracts with health plans in the state, bringing together partners in the coalition to successfully push forward a bill that requires insurance payers to recognize public health departments as in-network providers.[1] In addition, a pending bill, currently in study committee, would require payers to work with public health agencies and reimburse them for immunization services at a rate of 121%.

At the governor’s request, a Vaccine Financing and Availability Advisory Committee produced a report in December 2014 with recommendations on cost, purchasing, payment, and access to immunizations. This interdisciplinary committee report provided the most comprehensive information available to date on vaccine financing and availability in Arizona.


Footnote

  1. The bill, signed by the governor in May 2013, mandates that to receive reimbursement for the cost of immunizations, the local health department may enter into a contract governing the terms of reimbursement and claims with the corresponding private health care insurer. The local health department may enter into a contract with a private health care insurer on its own, in conjunction with other local health departments, or through a qualified intermediary. If the local health department chooses not to contract with a private health care insurer, or does not respond to the request to contract from a private health care insurer within 90 days of the request, the insurer is not required to reimburse the local health department for the immunization. If a private health care insurer declines or does not respond to a request to contract with a local health department, with a coalition of other local health departments, or through a qualified intermediary within 90 days of the request to contract, the private health care insurer must reimburse the local health department at the rate paid to an in-network provider.
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California (Kern County)

In June 2010, countywide budget cuts forced Kern County Public Health Services in California to consider scaling back its clinic services and possibly close its public clinic altogether. Fortunately, the county had launched a pilot billing program earlier in the year, and in the first six months of the program’s implementation, had seen a ten-fold increase in revenue. The results of the pilot program were presented to the county’s Board of Supervisors, which voted to maintain the health department’s immunization services and keep the public clinic open.

Though Kern County had some previous experience with billing, a planning grant from CDC enabled the expansion of its billing program. In addition to billing Medi-Cal and Medicare, the county now has contracts to bill multiple private insurance companies and is bringing in a new stream of revenue to help pay for the services the department provides.

According to Kern County's Denise Smith, establishing those contracts was the greatest challenge in building a successful billing program. "It was important to have the right person for the job," she says. "You need an effective sales rep who is outgoing and not afraid to cold call insurance companies and sell them on public health services."

Increased efficiency in billing has also played a key role in the county's success. Kern County used some of the funds from its CDC grant to hire an insurance specialist who identified coding errors and missed billing opportunities. Her work has been instrumental in achieving the significant increase in revenue.

Kern County's experience and success in billing has paved the way for other California counties to set up their own contracts with both public and private payers. Funds from the implementation grant provided by CDC were used to train six other local health jurisdictions in California to follow Kern County's lead and set up their own billing systems. The county has created a nationally recognized billing tool kit to assist other health departments, and its thriving billing program serves as a model for public health agencies nationwide.

California's Innovative Immunization Billing Project Plan [5.33 MB, 96 pages]

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Georgia

The Georgia Department of Public Health's private insurance billing program for immunizations began in January 2009 with a contractual agreement with the state employees' health plan for immunization services. Since then, billing revenue has made it possible to expand the immunization program by increasing the supply of privately purchased vaccines, including those required for international travel.

Today, the department has contracts in place to bill not only the state health plan (which includes United Health Care and Cigna), but also Medicaid/Medicaid CMOs, Peachcare for Kids, Medicare/Medicare HMOs, Blue Cross/Blue Shield's PPO and HMO, and Aetna's PPO and HMO. The department continues to work toward establishing contracts with all insurance payers in the state.

Georgia benefits from a centralized billing contract coordination that encompasses over 200 facilities in 159 counties within 18 districts, according to Kimberly Russell, Billing Specialist with Georgia's state health department. "We have a tremendous advantage in being centralized," she says, adding that local and county public clinic staff is focused on direct patient care and billing for services. Centralized contract negotiation is more efficient, resulting in common reimbursement throughout the state for local health department services. Georgia has one umbrella contract with each payer that includes all of its many public health entities.

The success of Georgia's billing program can also be attributed in part to its emphasis on accurate coding, which is a major factor in getting claims paid for immunization services, as well as getting the maximum reimbursement rate. Russell earned a certification in coding and has traveled throughout the state to train health department staff on how to code properly. She notes that standardizing efforts to ensure that billing procedures are consistent on the local and county level has also been important for the program's success.

Georgia has a mandate that revenue generated from billing must be reinvested in local public health efforts. Increasing access to immunization services, especially for the uninsured and underinsured, further connects those in need of other public health services.

The Georgia Department of Public Health Billing Manual

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Illinois

The Illinois Department of Public Health (IDPH) and the Illinois Public Health Association (IPHA) tapped the resources of an active, tight-knit public health community and built a strong foundation for the state’s billing program from the very beginning of the planning phase.

IPHA gathered data about the status of billing in the state by conducting a survey of local health departments, then held a meeting for stakeholders, including representatives from state and local health departments, the state insurance department, and professional provider groups. Ten pilot sites were chosen for the billing program, and a contractor was retained to provide a software system and technical assistance to facilitate the billing process.

The pilot program launched in July 2013, and training sessions on HIPAA rules and billing and coding were held for pilot site staff.

According to Jeffery Erdman, IPHA’s Assistant Director for Programs and Compliance, attempts to set up contracts with private insurance payers were met with some resistance. “The challenge was getting insurers to understand public health and how it operates.”

Carol Finley, Assistant Chief of the Illinois Department of Public Health, adds, “One of our struggles was getting recognized by private insurance as a legitimate provider of preventive services.”

At a CDC billing stakeholder meeting in August 2013, Illinois immunization program staff had opportunities to meet with several private insurance providers. The newfound personal connections assisted in the process of setting up contracts, and seven of the pilot sites are now billing Medicaid, Medicare, and 16 commercial insurance companies.

Illinois has 102 counties, many rural and underserved, so local health departments are often the only place for the underinsured to go for immunization services. After the pilot billing program brought in close to $1 million in revenue, it was clear that the funds generated through billing would allow local health departments to expand and enhance the immunization and other services they offer. IPHA already had a vaccine purchasing consortium that offers discounted pediatric and adult flu vaccine to local health departments, and a sustainable billing program could bring in revenue that might enable other vaccines to be offered, too.

Update: Illinois moved into the implementation phase of its Immunization Billing Project in October 2015. The project continues to build on its initial success through a strong stakeholder group, extensive training, and strategic use of resources provided by a third-party vendor. The program continues to expand, with funds granted in the project’s implementation phase allowing more local health departments to begin participating.

Twenty-four local Illinois health departments have now contracted with a third-party billing vendor, CDP, Inc., that offers access to a larger staff and technical support to assist with billing issues. Through CDP, the health departments use ezEMRx, an electronic medical records system that allows them to manage revenue throughout the billing cycle.

In January 2016, IPHA reported that the claims revenue received by health departments participating in the Immunization Billing Project is greatly exceeding expectations. From July through December 2015, the project generated $558,552 in paid claims for local health departments. Health departments have also found that using ezEMRx has made the transition to ICD-10 much easier. At a time when reduced funding is forcing many Illinois health departments to cut staff and services, this additional revenue is enabling health departments participating in the billing project to continue providing immunizations and other vital health services.

The project’s stakeholder group, an important key to the project’s success, remains active in advising on strategies and logistics.

Training for local health department staff has been another critical factor in the project’s success. Project staff arranged a series of training sessions to prepare health departments for the transition to ICD-10. Hosted by Blue Cross Blue Shield of Illinois (BCBSIL), the sessions also covered other issues, including free electronic resources offered by BCBSIL to assist with billing.

In addition, IPHA addressed HIPAA regulations and their impact on public health by offering a webinar for local health departments participating in the Immunization Billing Project.

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Massachusetts

The billing program in Massachusetts benefited from involving important stakeholders early in the planning process. The state’s public health commissioner met with a group of health plan policy makers, providing them with an opportunity to raise concerns about contracting with local public health agencies. Massachusetts Department of Health (MDPH) Immunization Program staff then developed strategies to address those concerns. They partnered with a former staff member of the Massachusetts Association of Health Plans, who identified key contacts in the health plans and assisted with arranging one-on-one meetings with decision makers.

One of the main insurer concerns, according to Donna Lazorik, who oversees the MDPH Immunization Billing Program, was that primary care providers might not receive records of vaccinations administered to their patients at local public health clinics. That issue was mitigated by increasing enrollment of local health departments in the statewide immunization registry.

Health plan representatives also expressed concerns about the policies which local health departments use to administer vaccines. Immunization Program staff reassured them by providing an example of the standing orders developed by the state health department, as well as an agreement signed by local health department medical directors to comply with state and federal requirements for administering Vaccines for Children vaccine.

Because the public health system in Massachusetts is decentralized, the billing program has partnered with Commonwealth Medicine Center for Health Care Financing, a division of the University of Massachusetts Medical School. Commonwealth Medicine acts as a clearinghouse and currently submits claims to all participating public and private health plans from local health departments throughout the state. Contract negotiations are underway with several additional health plans, and in July 2013, the program was expanded from billing only for influenza and pneumococcal vaccines to include all vaccines recommended for adults.

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Nevada

When the Nevada State Immunization Program received a billing planning grant in 2009, its decentralized health districts were all at different levels in their billing capacities. Some were doing limited billing, mainly Medicare and Medicaid, while others were already billing public as well as some private insurance payers.

Kathleen Haynie, project manager for the Nevada State Immunization billing program, began holding regular stakeholder meetings with representatives from local health departments, vaccine manufacturers, state immunization coalitions, the state immunization registry, and state Medicaid, as well as contracting specialists from some of the largest local private insurers, including Anthem Blue Cross/Blue Shield and Aetna. The state’s health districts decided to pursue billing independently on their own timelines, with the state program providing support and assistance in contracting and credentialing.

The Community Health Nurses in the Nevada State Health Division were already billing private and public insurance payers when Nevada received the billing planning grant. The grant allowed the clinics to evaluate their billing processes and begin making improvements to enhance efficiency and increase the amount of reimbursement they were receiving from insurance payers.

Carson City Health and Human Services was also billing public insurance and two private payers with the assistance of an external billing agency. With the planning grant, they were able to train staff and bring their billing process in-house. The result has been a self-sustaining billing program, with improved follow-up on denied claims, as well as several new contracts with private payers.

Haynie says the main key to Nevada’s success has been early stakeholder involvement to secure “buy-in” from all parties involved in billing. Early success in two of the state’s health departments has underscored the value of billing and shown other districts and health departments the potential benefits of billing in their areas.

The state immunization program continues to provide billing support, and Haynie has developed billing policies and procedures, as well as a front-office training module for billing.

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