SITUATION:
Our client was working with another vendor to claim Fee-For-Service (FFS) Medicaid reimbursements using their IEP software. However, with little visibility into how these claims were being developed, the District’s only benchmark for success was a year-over-year comparison of Medicaid revenue received, rather than comparing what they were entitled to bill for (based on IEP services and eligibility information) against actual revenue. In addition, the system in place did not provide sufficient Medicaid compliance assurance, which resulted in several negative audit findings. As a result, our client was not maximizing Medicaid claiming opportunities and was not comfortable with overall program compliance. In addition, our client had difficulties engaging their state Medicaid agency in policy discussions concerning restrictions in the claiming program centered on TPL based denials and other restrictions to the program. The Medicaid agency was also implementing a new claiming workflow by creating an oversight agency to ensure proper validation of all claiming elements prior to claims being submitted to them. Unfortunately, the implementation of the oversight agency and inconsistent data matching led to many examples of valid claims being denied unnecessarily.
SOLUTION:
In order to maximize our client’s Medicaid revenue and manage compliance, Accelify implemented its Medicaid claiming management system, AcceliCLAIM. AcceliCLAIM automates the process of identifying, validating, and submitting valid Medicaid claims. Because the data needed to build claims was coming from multiple sources and in different formats, Accelify developed a custom and intuitive interface for importing all required data files and running intricate validation routines. The custom solution seamlessly merges and validates the data to create claim files. Building the complex system involved working with the Medicaid agency and the newly formed oversight organization, to set up compliant Medicaid billing processes and procedures. Accelify managed all the moving parts and parties to integrate its products under tight deadlines. Furthermore, when the State changed the amount of time allowed for back claiming from 24 months to six months mid-project, Accelify adjusted its deadlines and deliverables to ensure maximum reimbursement for retroactive claims.

In addition, Accelify participated in weekly calls with our client, the Medicaid agency and the oversight organization. During these calls, our client was able to engage the Medicaid and oversight agency on policy issues such as creating a TPL methodology that would allow for a process to seek reimbursement for these claims. Accelify was able to provide examples of how various state Medicaid agencies across the country set up their TPL processes that our client used to ultimately have the Medicaid agency define its own TPL policies. This led to our client submitting hundreds of thousands of dollars in claims for that had been denied in the past.

Accelify’s project team also undertook the responsibility of identifying major gaps in the claims processed by the previous vendor. Accelify compiled and compared service documentation data to claims paid data and identified almost $1,000,000 in claims that had not been properly submitted. Accelify then coordinated the efforts between several system data teams to import all necessary claim validation points into the AcceliCLAIM system to ensure that the retroactive claims were still validated fully before being submitted for Medicaid reimbursement.
RESULTS:
Accelify’s AcceliCLAIM solution has provided our client’s staff unmatched visibility into the claiming process with robust reporting tools on service and claim data. This visibility has allowed them to identify additional Medicaid-eligible students and bill additional allowable services that were previously unclaimed. The District has gained control over the claim development process, resulting in significant revenue increases. In the first 12 months of the project, our client received over $3.5 million in reimbursements, which represents a 900% percent increase over the previous 12 month period.

Due to the success of the project, Accelify has begun work on several other claiming initiatives including claiming for Non-Public schools, services provided in charter schools, transportation services provided to both charter school and non-public school students, and cost reconciliation reviews. These initiatives project to produce another additional $1,000,000 or more in increased reimbursements.

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