Medicaid in the States: A Proactive Approach With state budgets in rough waters, professionals can seek opportunities to collaborate with state associations to present data to state Medicaid agencies. Medicaid, a joint federal/state reimbursement program that provides health care to low-income families, is one of the fastest-growing fiscal programs in most state budgets. It is also a ... Features
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Features  |   July 01, 2003
Medicaid in the States: A Proactive Approach
Author Notes
  • Thomas J. Hallahan, is an associate professor of communication disorders at Salem State College in Salem, MA, and serves as audiology consultant to the Massachusetts Division of Medical Assistance and Department of Public Health. He may be contacted at thomas.hallahan@salemstate.edu.
    Thomas J. Hallahan, is an associate professor of communication disorders at Salem State College in Salem, MA, and serves as audiology consultant to the Massachusetts Division of Medical Assistance and Department of Public Health. He may be contacted at thomas.hallahan@salemstate.edu.×
Article Information
Practice Management / Features
Features   |   July 01, 2003
Medicaid in the States: A Proactive Approach
The ASHA Leader, July 2003, Vol. 8, 4-5. doi:10.1044/leader.FTR1.08132003.4
The ASHA Leader, July 2003, Vol. 8, 4-5. doi:10.1044/leader.FTR1.08132003.4
With state budgets in rough waters, professionals can seek opportunities to collaborate with state associations to present data to state Medicaid agencies.
Medicaid, a joint federal/state reimbursement program that provides health care to low-income families, is one of the fastest-growing fiscal programs in most state budgets. It is also a target for budget reductions, as most states are currently facing shortfalls in revenue.
In the Commonwealth of Massachusetts, for example, funding for the state Medicaid program (MassHealth) accounts for 25% of the annual budget. Therefore, as practitioners it behooves us to be proactive and become key players in working with state Medicaid agencies in setting policy and developing regulations.
Professionals must learn to work within collaborative groups such as their state associations to gather, analyze, and present clear data from outcome measures and cost studies to provide vital information to state Medicaid agencies. Often the state rate-setting entities and policy-makers are looking not only for input, but also for direction in developing policy and practice guidelines, and in determining reimbursement rates.
In an attempt to better understand our practitioners and address their needs, the MassHealth program surveyed audiologists on how we could improve our working relationship. One of the recurring complaints from providers centered on the lack of adequate reimbursement for the fitting of hearing aids requiring more technical expertise (i.e. digital, programmable). In response, MassHealth administrators requested data on time allocation, equipment costs, and increased clinical training that such devices would require of the provider in order to appropriately deliver these services to the recipient.
The Massachusetts Speech-Language-Hearing Association, as well as individual providers we surveyed, had no such data and neither did any of our national associations. However, ASHA had a well-developed system already in place to respond to the request through its Health Care Economics Committee, which consists of five audiologists and five speech-language pathologists. This committee, with resources for performing surveys and other data-gathering, conducts the behind-the-scenes work that is essential for both our state and national associations if we are truly going to be an integral part of determining health care policy.
The Role of State Associations
The Florida Association of Speech-Language Pathologists and Audiologists (FLASHA) offers a prime example of a state association that has blazed such a trail. In the early 1990s, no state or national association had developed a systematic approach to gather and analyze outcomes and efficacy data of the numerous treatment approaches for communication disorders. FLASHA, in response to the Florida Health Care and Insurance Reform Act of 1993, organized a collaborative effort by its members and developed one of the first tracking forms and analysis of outcomes data in our fields. These data also were used in the development and implementation of relevant practice parameters for patient management.
Several other states—either independently or building upon Florida’s initiative—have collected and studied treatment outcomes in an effort to broaden scope of practice guidelines within their states’ licensure regulations or, more commonly, in response to changes in health care policy.
The Value of NOMS
Presently, ASHA is the only national association in the discipline of communication sciences and disorders with an established network dedicated to the collection and analysis of outcomes data—the National Outcomes Measurement System (NOMS). It’s also important that our state associations or working cohorts spearhead their own efforts in collecting outcomes, efficacy, and costs data, either within regional projects or national leadership groups, such as the Council of State Association Presidents. A 1996 ASHA publication, Treatment Outcomes and Efficacy: A State Resource Guide, would be a valuable resource for such an endeavor. In addition, ASHA has a history of providing substantial grants to state associations to pursue such projects through its State and Consumer Advocacy Team.
HIPAA and Medicaid
Medicaid is also undergoing revisions because of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which was enacted to streamline and standardize the administration of health care insurance. HIPAA also addresses privacy of patient data in this era of electronic data interchange. HIPAA privacy rules apply only to providers who submit electronic claims transactions directly or through contracted clearinghouses. The regulations also affect (but are not limited to) patient medical information and Web-based recipient verification systems.
Providers must note that, although they may continue to bill by paper only, changes driven by HIPAA related to attachments may ultimately affect them too. A number of audiology and hearing aid services require paper attachments to each claim form, in turn requiring a paper transmission of billable services. HIPAA specifies that it is up to each payer, may it be Medicaid or a private insurer, to design a system that would accept attachments and enable independent providers to bill electronically. Therefore, providers could electronically bill the services provided, and then either fax or mail the paper attachments (depending on the system the payer develops). The immediate benefit would be the elimination of key error entries on the part of the payer’s data entry staff. However, the obvious downside to such a process would be the uncertainty of paper attachments being successfully coupled to the electronic submissions.
The earliest concerns of most professionals regarding HIPAA implementation seemed to focus on the regulations protecting the security and privacy of patient information. This was the initial portion of the HIPAA regulations, released to the public with a compliance deadline of April 14, 2003. There has been much confusion around privacy rule compliance, with numerous misconceptions spreading quickly through the professional community. Although there are specific changes dictated by HIPAA in how we process patient information, much of privacy rule compliance should have already been in place within our practices. Furthermore, as stated earlier, only those health care providers who are transmitting electronically and/or using an approved clearinghouse need to comply with HIPAA privacy regulations.
Elimination of Local Codes
As a practitioner, I am most concerned with changes that will occur with the implementation of the 837 Professional (837P) HIPAA-Compliant Electronic Claim Format and its effects on reimbursement codes, specif ically the elimination of payer-specific (local) codes. To be HIPAA-compliant, each payer will be required to delete local codes and use only Common Procedural Terminology (CPT, ©American Medical Association) codes for procedures rendered and Healthcare Common Procedure Coding System (HCPCS) codes for supplies, devices, and equipment. Also, every payer must implement a proper electronic claim format by no later than Oct. 16, 2003. There will be revenue implications as a result, since a number of local codes have no corresponding CPT or HCPCS code.
The Massachusetts Medicaid program has had to either eliminate or revise more than 20 codes within the audiology and hearing aid programs alone, in order to comply with HIPAA. Providers may be unaware of these drastic changes and most likely will not realize them until claims have been denied for coding errors, further delaying an already cumbersome reimbursement process.
To help ensure timely reimbursement, providers should contact their state’s Medicaid program and private payers to ensure that they are meeting the standard HIPAA transaction requirements, hopefully ensuring timely reimbursement. As an alternative, providers also may obtain this information by visiting their state’s health care and finance division Web site (for example, in Massachusetts providers can log on to http://www.mass.gov/dhcfp) or contacting their state’s HIPAA support center.
When billing electronically, independent practitioners in communication disorders will be required to use the 837P electronic claim format (institutions and hospitals will use 837I). If one continues to choose to bill by paper—HIPAA cannot force providers to send in electronic claims—there is likely to be only minimal change in the present billing process, with the exception of those involving the elimination of local codes. In addition, each payer is required to develop a companion guide to assist providers in understanding the technical and data-entry requirements for the 837P format. Most of these should be easily accessible, via download or hard-copy request, from a payer’s Web site.
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July 2003
Volume 8, Issue 13