Florida Early Steps Providers are Requesting a Change in the Billing and Payment Procedures, etc.

To Dr. Jeffrey P. Brosco Deputy Secretary of CMS and Early Steps of Florida. 

I am writing this letter on behalf of the agencies currently invoicing Early Steps for services. There are several barriers that we have been challenged with that prevent us from timely filing claims. Here are the many barriers we are facing:

• We are asking for a way to have our paperwork reduced,
• A way to make the administrative tasks more efficient,
• We want to be paid for our services rendered and in a timely manner,
• The current process does not mirror insurance processes and creates triple and quadruple work for the agencies and for the Early Steps Programs.
• We are often asked to duplicate or asked to perform a different billing procedure by each Early Steps program, and that increases the cost for agencies to operate and remain profitable to pay our providers.

The issues are listed below as described by our current Early Steps providers. 

1) Insurance companies allow 90 days to file a claim and a claim may also be resubmitted if more information is needed. Early Steps only allows 60 days. We get our EOB's in 45 days and if we are out of network it may take longer and more difficult to get them. Then we are past the 60-day timely filing limit. We should have the ability to re-submit claims and appeal it like the insurance companies do. We should have a year to re-submit claims as the state of Florida allows for Medicaid claims.

2) Some clients have a commercial insurance primary and a Medicaid insurance is secondary and we need to bill the primary first and then the secondary to get paid. It takes 45 days to get the initial EOB. Then we bill Medicaid and find that the client is no longer covered by their plan and now we can't get paid by Early Steps because it is past the 60-day timely filing limit.

3) Billing amounts allowed by insurance differ than Medicaid and Early Steps. For claims that must be submitted to Early Steps when the insurer won't pay, a brand new claim must be submitted with the Early Steps rate rather that Early Steps adjusting for the claim for their rate. For instance: If a company charges $100.00 for Speech Therapy services but Early Steps will only reimburse $71.44 then we have to make a whole new claim or write on this current claim with a pen and rescan it and send it on a secure e-mail. This is duplicate work and requires more administrative pay to billing personnel that cannot be recouped. There is also a question of potential fraud for filing claims with differing amounts to two different payer sources.

4) ATA/HN1 claims are creating issues across all therapy providers as ATA pays at a lower rate and if Medicaid pays, then Early Steps doesn't. Professional therapists are asked to see children at a rate that is almost as low as minimum wage. Early Steps also requires us to see children for an hour once a week and therapists are getting paid more than the agencies are getting reimbursed. This is not a good business model. There are 26 weeks in a 6 months period and the levels do not reimburse enough for even once a week. We are at the discretion of ATA/HN1 on what level they want to give us for reimbursement. Many of us our opting out of being providers for them because of this change.

5) Many providers never invoice for travel due to the cumbersome and time-consuming process. We must include a map and then change the rate to .445 cents per mile and electronic systems always round the number up and we are required to put the exact rate on our claims. This is very time-consuming. We must print, scan and then upload to the Move It system. This takes hours of our time to submit claims.

6) Smaller agencies, especially, cannot keep up with all the forms that must be submitted, often to different people. Each Early Steps program requires different billing procedures. One Early Steps can be 2-3 months behind in paying us and the other one can be quicker because we can send claims as often as we like. When we had Med3000 we were paid a lot faster and there weren't these types of gaps in payment.

7) The cost of processing claims, especially for smaller agencies, is exorbitant and providers must absorb this cost which continues to rise despite the rates remaining the same or in the case of the ATA as rates much lower. It requires more office staff than what the profit would be from Early Steps. We are not in business to do free work or go in the red. We can't stay open if this continues.

8) If you have trouble getting EOB's (if you are out of network), then you can't file your claims within 60 days as Early Steps requires. It takes 45 days to get an EOB and if you are out of network they must mail the claims to you and you have to sign up to get them mailed to you. There is usually no way to get them electronically in a fast manner. You have to call and then it takes them another 45 days to set it up.

9) The COIFF (IFSP Meeting) or CONIF (Consult Face to Face) was not added to your Auth in Early Steps Electronic system by the service coordinator. Now your COIFF or CONIFF was denied and then can't be re-submitted in time. We get denials from Early Steps Part C dollars when the Provider attended the meeting or consult. It is not fair that we are not paid for our services that we are rendering.

10) Your travel or NESF was missed and tried to rebill it and was denied. This is a Part -C payment and a government program. These types of services should allow a year to be reimbursed since the state of Florida allows a year to bill Medicaid Claims. If we performed the service, we should be paid for it. If you want us to continue providing services for your clients, we shouldn't have a hard time getting paid.

11) The denial reason on your EOB was not a usual denial reason. For example: if the reason said for a licensed provider providing EI Services the denial reason came back "services cannot be billed separately." Then when we called the insurance they said that code was supposed to be billed with another code, but they couldn't state which code it needs to be billed with exactly. They were going to send it back to claims to look at it, but she stated that they probably won't change the denial reason anyway or add a new reason. Even though they are resubmitting it to Claims it will take another 60 days or so to see if they will add a new denial reason. Early Steps won't pay us because they don't like the denial reason. The EOB is evidence that they are not paying and now Early Steps is the payer of last resort and needs to pay for these services. End of the story! Months have gone by where the agency was not paid at all for these services due to the same denial reason. That is out of the agencies control of what the insurance will put on the EOB.

12) Sometimes Insurance carriers make mistakes on their EOB's,for example: they put the wrong provider on the claim or ask for speech therapy notes when we don't have speech therapy notes because we are providing Early Intervention. Again, this delays the Agency from getting paid and this should not be the case with a government program. It already takes about 5 to 6 months to get paid from commercial carriers due to this process. We are waiting too long to get reimbursed by your Early Steps program.

13. Early Intervention is a habilitative service (meaning the child was born with a delay and needs to learn new skills) and commercial carriers do not cover habilitative services. They only cover rehabilitative services. Rehabilitative services are services that are provided to individuals who used to be able to have a skill and had lost that skill due to an injury, stroke, congenital anomaly. Billing insurance is a waste of time for T1027 SC or 96154 or G0515.

Early Steps falls under the Idea Law Part-C. This is under and education grant not a medical treatment. Insurance should not be billed for coaching and training parents in the natural environment. The Individuals with Disabilities Education Act (IDEA) is a four-part (A-D) piece of American legislation that ensures students with a disability are provided with Free Appropriate Public Education (FAPE) that is tailored to their individual needs.

Some solutions that are proposed:

1) Allow providers to invoice directly into the state system. If this is a goal for Early Steps, please put it as a top priority before more providers exit the system.

2) Consider paperwork reduction for filing of claims.

3) Work with the providers in filing a petition to AHCA to address the ATA/HN1 issue. Early Steps should pay the difference of the Medicaid rates of Florida for ST, OT and PT of $71.44 so we can continue to be Early Steps providers and provide services for your clients. ATA will only give us levels and if we have several visits that can end up being $13.00 a visit or less. The levels now include the initial Evaluations and Re-evaluations. The levels are: Level 1: $72.00, Level 2: $180.00, Level 3: $320.00, Level 4: $420.00 and Level 5: $600.00. There are 26 weeks in 6 months. If we see a child 1x/week that is 26 visits. If we see a child 2x/week that is 52 visits. We usually get a level 3. Sometimes we get a Level 2 also. We are not able to get upgrades now since June 1, 2018. What ever level ATA/HN1 gives us is what we get. There is no appealing it now. Many providers are ending their contracts with ATA/HN1 because of this new model they are using. We are complaining to AHCA and fighting this issue as we speak.

4) Consider taking the requirement of the "time in" and "time out" and the word "home" or "Daycare" off box 32 and off the claim form as this is already on session notes and is a reason for denying claims when it is omitted. We shouldn't have to add time in and out and Home or Daycare to our claims anyway because we are contractors and we keep our own notes. The Home and Daycare is in the Place of Service Code and this is redundant to add the words home or daycare to box #32. We don't write in your own note taking system so if you want our notes we can provide it for you, but we shouldn't be required to submit time in and out all of the time and write the place of service on your claims every time. We have to print it out and write on it or type on it extra in our Electronic systems and it takes longer to process claims. We have to print out the claims and put them in order and scan them together and then send it on a secure move It system. This takes hours of our time. Hours to just get a few hundred dollars. This is not cost effective. This is also time consuming for the Early Steps programs too. This is not cost effective for both the agencies and the Early Steps programs.

5) Consider allowing therapy providers to use their original claims for billing Early Steps when there is a denial.

6) For smaller agencies that only invoice early intervention services or only have a few providers, please allow a spreadsheet that mirrors the state system rather than claim forms for each child. Billing packets for each provider are enormous and result in massive input into Move It secure e-mail system to process them. Agencies should be given an option of how they want to bill if we continue to use paper claims. This billing process is archaic. The smaller companies like spreadsheets and the larger companies like using HCFA 1500 claim forms. When we had Med3000 to bill it was so much easier for everyone. If we can have an electronic system again that would be beneficial to all agencies and all Early Steps Programs.

7) Give us more time to submit EOB's to you and do not penalize if we are out of network with an insurance company. Otherwise we might not be able to take these children anymore if we are out of network with any insurance carrier. This will limit your ability to find providers. Anyone that is out of network with an insurance agency should have CONT be the payer of service.

Your consideration of this input to move to a more efficient and cost effective system is appreciated. Several providers in the Bay Area, the West Central Area and other parts of Florida would be glad to meet to discuss other potential challenges and solutions. We would like a solution fairly quickly or most of us will have to drop out of the Early Step Program as providers. We can't afford to continue to lose money when doing business with Early Steps. These processes are causing many providers a large financial loss. We would appreciate a solution within thirty days if possible.


Sincerely,


Many Florida Early Steps Agencies and Providers.