Multi-State Medical Billing Services: How to Manage Revenue Across Multiple States
Healthcare practices are breaking out of their regional bubbles:
physician groups operate businesses in multiple states, providers offer behavioral health services through telehealth in other states, and expanding organizations develop broader networks of providers.
With the growth comes the need to consider revenue cycle management (RCM): just because a practice has a billing system in place and multiple locations does not mean that its billing is simple.
Multi-state practices need to work with multiple Medicaid programs, payer networks, provider enrollments, Medicare contractor jurisdictions, telehealth regulations, and documentation guidelines. It requires a strategic approach to claims, payments, denials, and accounts receivable in order to manage the revenue cycle efficiently.
This is when multi-state medical billing services can become helpful.
What Is Multi-State Medical Billing Services?
Multi-state medical billing services represent revenue-cycle management services for organizations that operate, employ providers or contractors, or provide services to patients in more than one state.
The key is that a competent RCM company manages billing on a unified basis while considering the requirements specific to each entity, location, payer, and state.
Such services usually include
eligibility and insurance verification services,
charge entry and coding reviews,
claims submission and rejections,
payment posting and reconciliation,
denial management,
follow-ups on accounts receivable,
provider credentialing, and
payer enrollment and CAQH maintenance and recredentialing,
reporting, and other revenue-cycle services.
The objective is to ensure standardized and controlled processing of claims with the attention to all requirements specific to entities, locations, payers, and states.
Why Is Multi-State Medical Billing More Complex?
A single-state medical practice with multiple payer contracts and requirements may seem complicated enough. Now imagine bringing the same into multiple states each with its own Medicaid programs, provider networks, billing rules, documentation guidelines, and more.
1. Medicaid Enrollment Is State-Specific
According to CMS, “Medicaid and the State Children’s Health Insurance Program (SCHIP) are jointly administered by the federal government and the states. Eligibility and scope of benefits may vary among states, and providers who wish to participate in Medicaid or SCHIP must apply in each state in which they wish to furnish services.”
In other words, a provider cannot automatically participate in the Medicaid program of one state by virtue of participation in another one. And, as many multi-state practices learn, it is important to track Medicaid enrollment by provider, state, entity, location, and payer.
2. An NPI Does Not Equal a Payer Enrollment
According to CMS, “An NPI number does not indicate licensure or certification by any government agency… It also does not guarantee payment by a health plan. Finally, it does not enroll you with any government or private third-party payer.”
This includes Medicare, which means that a practice has to take additional steps to enroll in Medicare as a provider. In short, an NPI number is necessary, but it is not sufficient for multi-state practices to bill any payer in any state.
3. Provider Credentialing Needs to Be Carefully Managed
Provider credentialing is another important aspect of managing a multi-state practice.
When a physician practices multi-state medicine, joins a physician group, opens a new location, or contracts with a new payer, his or her records have to be updated accordingly in a standardized manner.
According to CAQH, “The CAQH Provider Data Portal offers a comprehensive solution to payer enrollment and credentialing requirements. By using our credentialing application, found in the Provider Data Portal, you can complete one widely accepted application for all 50 states (and the District of Columbia).” At the same time, each payer and state can have additional requirements, and it is important to track them.
Important information includes licenses, location, taxonomy, malpractice insurance, ownership structure, participation details, and recredentialing dates. In short, every multi-state practice needs to make sure that this information is up to date and consistent across entities.
4. Telehealth Needs to Follow State Laws
The adoption of telehealth services has contributed to the rise of multi-state medical practices, but it does not make them any less subject to state laws and payer requirements.
Under the guidance from the U.S. Department of Health and Social Services, “A physician may practice medicine in more than one state, but must satisfy licensure requirements in each state in which he/she provides medical care. There are a number of ways for physicians to meet this requirement including full licensure in each state, temporary licensure, reciprocity agreements, licensure compacts, and telehealth registration.”
Physicians providing telehealth services across state lines must also consider where the patient is located for the purpose of determining the state where the service takes place. In fact, HHS notes that “a telehealth encounter takes place in the state where the patient is located at the time of the encounter for the purposes of this guidance.
This affects how a claim is processed and paid. In other words, the billing team has to understand the combination of provider – license – patient location – payer – service – claim.
In short, a multi-state medical practice with telehealth services needs to be aware of state-specific requirements for both sides of the encounter.
5. Medicare Claims Are Subject to Jurisdiction-Specific Processing
While Medicare is a federal program, it is administered by different Medicare Administrative Contractors (MACs), each of which covers a jurisdiction of several states.
For instance, Medicare A/B MAC Jurisdiction H covers Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas, while Jurisdiction K includes Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, and Vermont. In other words, a multi-state practice sending claims to Medicare has to be aware of the MAC jurisdiction and its specific requirements for each state.
What Is the Ideal Multi-State Medical Billing Workflow?
An efficient multi-state billing workflow follows the same general principles as any other revenue cycle but adds the ability to centralize and manage data while being aware of the details unique to each provider, location, payer, and state.
Here is a suggested billing workflow for multi-state practices:
1. Develop a Provider and Location Master File
Begin with a master file that has the key fields needed for determining the appropriate processing of a claim. It can include a provider’s NPI, taxonomy, licenses, locations, group, tax ID, enrollments, effective dates, and other relevant information. The idea is to have a single source of data that can be used consistently by all locations and avoid inconsistencies between different teams.
2. Create a Payer Matrix
Another central element of a multi-state billing workflow is a payer matrix that shows which providers and locations are enrolled with which payers. Ideally, the matrix includes the following information:
State Provider Location Payer Enrollment Effective Date Recredentialing Date
This way, the billing team has a reference outlining which payer a claim needs to go to, considering the provider, the location, and the patient.
3. Front-End Eligibility and Benefits Verification
One of the most frequent sources of claim rejections and denied claims is inaccurate patient eligibility information. That is why a billing office has to verify patient eligibility and benefits during the front-end of the revenue cycle while ensuring that all other requirements (authorization, etc.) are met.
This information is usually obtained from the payer at the time of eligibility verification. It helps the billing team determine whether the visit is covered under the patient’s policy and whether there are any additional requirements, such as preauthorization or pre-certification, that the practice needs to fulfill.
At All State RCM, we incorporate eligibility verification into our upstream billing management process and review this information before claims submission.
4. Review of Documentation and Coding
The next step is to ensure that the documentation supports the codes and that the billing accurately reflects the services provided.
A coding review can identify errors related to ICD-10-CM diagnosis coding, CPT and HCPCS procedure coding, modifiers, units of service, and other elements of the claim. This is especially important for multi-state billing, where the practice includes a variety of specialties and settings, such as telehealth services.
5. Manage Rejections and Denials by Root Cause
A multi-state practice will inevitably deal with claim rejections and denials from various payers. To ensure efficient handling of these rejections, it is helpful to determine their root causes and develop procedures to prevent future ones.
Using the examples above, the following categories can be used for grouping rejections and denials:
State Payer Provider Location Code Reason
This way, when a denial falls under the same category, the same root cause can be corrected to prevent similar rejections in the future. For instance, if a certain payer, because of the service location, is routinely denying claims for preauthorization reasons, the practice needs to establish a different process for filing these claims rather than resubmitting them in the same manner.
6. Follow an Efficient A/R Workflow
The more providers, payers, and locations a practice has, the more important it is to have an efficient accounts receivable (A/R) workflow that prioritizes collections based on aging, value, and filing deadlines.
As a general rule, an A/R office should follow the following order of priorities when pursuing delinquent claims:
A/R Aging Date of Service Amount Due Date of Filing with Payer Denial reason Recoverability
This way, the A/R team can follow the most critical delinquent claims first and avoid wasting time on claims that are unlikely to be collected or those that have exceeded the filing deadline.
7. Develop Reports Based on State and Overall Performance
The efficiency of a revenue cycle depends on the ability of an organization to consistently monitor and analyze its performance.
A multi-state practice, in particular, benefits from generating reports that compare and contrast the performance of different locations and providers while delivering the overall picture of the revenue cycle.
Reports to consider include clean claim rate, denial rate, A/R aging, days in A/R, payments, outstanding claims, rejections, and payer performance. Having these reports on a regular basis can help an organization spot trends and address problems in a timely manner.
What Are the Benefits of Outsourcing Multi-State Medical Billing?
For a growing multi-state medical practice, the most logical choice is to invest in a single billing company that can offer a nationwide but state-specific approach to RCM rather than hire and manage multiple teams.
When compared to in-house solutions, outsourcing multi-state medical billing can deliver the following benefits:
Greater operational consistency
A centralized approach ensures standardized processes and reduces the likelihood of errors.
Improved oversight
An efficient billing company will report to the practice with regular updates on the status of claims, accounts receivable, denials, and other aspects of the revenue cycle.
Safer denial management
A centralized denial management process can ensure that denials are prevented, analyzed, and recovered consistently.
Simpler expansion
In the case of a new location, a centralized billing team only needs to follow the established standard operating procedures rather than onboard a new team and implement in-house processes.
Reduced administrative burden
By delegating day-to-day billing and RCM responsibilities to a trusted partner, a medical practice can focus on providing high-quality care to patients.
Better coordination of credentialing and billing
The two functions should be managed together since payer enrollment and effective dates influence a provider’s ability to bill each payer in a certain location.
What to Look for in a Multi-State Medical Billing Company?
Not all medical billing companies are the same, which is why a practice has to understand its own requirements before selecting an RCM partner. In general, the following aspects of a multi-state practice should be considered when choosing a billing company:
State-specific payer enrollment;
Provider credentialing and recredentialing,
Denial management and recovery,
At the same time, it is important to establish what exactly a billing company is going to do. A competent RCM partner will develop a detailed service description that outlines the services provided, practice requirements, reporting, billing specifics, and exclusions. All State RCM, for example, offers medical billing and revenue-cycle services that include eligibility verification, coding review, claims submission, payment posting, denial management, A/R follow-up, credentialing, and reporting, among others, with the exact services determined for each practice.
Why a State-Aware RCM Strategy
The most common mistake that a multi-state medical practice can make is to believe that nationwide equals standardized.
In reality, while a centralized approach to RCM is beneficial, the processes have to be adjusted to reflect the requirements of states, payers, locations, and providers. CMS, Medicaid, and HHS resources are evidence enough of the number of variations that arise due to the involvement of more than one state, ranging from differences in Medicaid enrollment and provider networks to licensure and Medicare claim submission.
With that in mind, multi-state medical billing is really about nationwide consistency with local considerations.
Multi-State Medical Billing Services from All State RCM
Multi-state medical practices can continue to grow while maintaining an efficient revenue cycle with the help of professional billing and RCM services from All State RCM. We assist healthcare organizations in optimizing their revenue-cycle operations, from eligibility verification to coding review, claims submission, payment posting, denial management, A/R follow-up, credentialing, and more. Our multi-state medical billing services can be tailored to the specific needs of an organization in terms of specialty, payers, systems, providers, and more.
Whether an organization has multiple providers or is expanding its operations, a competent RCM partner can help ensure that the billing process remains organized. This way, the practice can focus on its core mission of delivering high-quality care to its patients while leaving the administrative and revenue-cycle responsibilities to professionals. Contact us to learn more about our multi-state medical billing and RCM services.
Website: www.allstatercm.com
Email: info@allstatercm.com
Phone: (206) 486-8646
FAQ
What is multi-state medical billing services?
Multi-state medical billing services represent revenue-cycle services for organizations that operate, employ providers or contractors, or provide services to patients in more than one state.
Do medical billing rules change from state to state?
Certain rules and guidelines, such as Medicaid participation and licensure, do apply on a state level.
Does having an NPI allow a provider to bill in every state?
No, a provider’s NPI number does not ensure licensure or credentialing by any government agency or third-party payers.
Can medical billing companies support telehealth practices across multiple states?
Yes, billing companies can support practices that offer telehealth services in multiple states; however, providers need to be aware of state-specific requirements.
Why should credentialing and billing be connected?
Credentialing and billing should be connected because payer enrollment and effective dates impact a provider’s ability to bill each payer in a certain location; thus, reducing preventable enrollment-related claim rejections and denials.
