Case Studies

Client Profile
ADA: 75,000
IEP Students: 8,100

AcceliCLAIM brings transparency to Medicaid claiming program for large urban school district, resulting in a 1000% increase in revenue with a near zero percent denial rate.

PROJECT OVERVIEW

MEDICAID INCREASES

$2.7mm

DENIAL RATES

<5%

When our client contracted with us to manage Medicaid billing for health-related services provided to their students with disabilities they had two key project goals:

INCREASE MEDICAID COMPLIANCE
Historically, our client had been penalized by several negative audit findings due to the prior vendor not providing sufficient Medicaid compliance assurance. As such, they were seeking a vendor who could better manage the process of validating claims prior to submission to the state Medicaid agency, in an effort to reduce overall claim denial rates and protect the District from future audits.

MAXIMIZE MEDICAID REVENUE
The District also felt it was not maximizing the claiming program. With little visibility into which services were (and were not) being claimed, the status of payments, and the reasons for claim denials, the District did not know where they could improve processes, obtain missing data, or update information in order to claim additional services or resubmit erroneously denied claims. The District needed a solution that would make the billing process more transparent, so they could identify new billing opportunities and maximize potential revenue.

THE SOLUTION

IMPLEMENT SYSTEMS THAT PERFORM COMPLEX MEDICAID VALIDATIONS AND AUTOMATE CLAIM BUILDING TO ENSURE PROGRAM COMPLIANCE
Accelify began the project by working with the District’s IT staff to identify the source for each of the data elements required to properly validate claims (i.e. Medicaid eligibility, parental consent, valid IEP, provider license, etc.) and establish a process to securely transfer all the validation data and service records to Accelify on a monthly basis so Accelify could build claims. Accelify’s proprietary claiming software, AcceliCLAIM, uses this data to perform multiple validations on each health service record prior to building it into a claim.

DELIVER ACTIONABLE DATA TO DRIVE REIMBURSEMENT
In addition to establishing a process to validate service claims prior to submission, Accelify’s systems have provided our client visibility into the entire claiming process, allowing them to identify additional revenue opportunities. This includes:

  • A comprehensive set of Revenue Exception reports that detail where missing parental consent, provider license, and other information is preventing otherwise claimable services from being claimed.
  • An interface to research denied claims by denial code and resubmit those that deny in error.
  • Detailed revenue analysis reports for reviewing Medicaid revenue by individual claim, month, school, service type and other factors to analyze trends and identify any outliers that may require attention.

 

PROVIDE REGULATORY GUIDANCE TO MAXIMIZE EVERY BILLING OPPORTUNITY
Accelify’s many years of experience managing Medicaid programs for school districts throughout the country provides us with a unique view of how various states interpret the federal policies that govern school-based Medicaid billing. Often times, this experience allows us to identify where certain state Medicaid agencies are misinterpreting policies in ways that unnecessarily limit claiming and advocate on behalf of the district to make changes to those policies.

For our client, Accelify provided regulatory guidance concerning the policy that resulted in the client’s state Medicaid agency denying claims for students with private insurance, otherwise known as Third Party Liability (TPL). According to Medicaid agency, TPL was a valid denial, as Medicaid was the payer of last resort. Accelify prepared a comprehensive report detailing how other Medicaid agencies handled payment for students with TPL, which our client presented to their state Medicaid agency. This report ultimately led to the agency creating a clearer TPL policy that would approve payment of claims for students with TPL, in addition to allowing our client to resubmit claims that had previously denied for TPL.

THE RESULT

Accelify’s work with has resulted in substantial gains in Medicaid revenue and compliance.In year one, Accelify increased Medicaid revenue over 1000% and has continued to enhance the program, with year-over-year increases that have led to annual payments of over $2.7mm for our client.In addition, denial rates have been reduced from 40% to less than 5% of claims–a clear indicator of more compliant claiming procedures.