Navigating the complexities of third-party billing is essential for healthcare providers, especially in the public health sector. Effective billing processes not only ensure financial sustainability but also expand access to vital services for underserved populations. As public health providers face decreasing government funding, mastering billing procedures becomes crucial to maintaining and enhancing community health initiatives.
Understanding how third-party billing operates can significantly impact a healthcare organization’s revenue cycle. This process involves billing private and public insurers, such as Medicaid, Medicare, and commercial insurance plans, for services provided by healthcare professionals. Despite its importance, many local health departments (LHDs), community-based organizations (CBOs), and healthcare providers (HCPs) have yet to develop the capacity to bill these payers effectively. Building this capacity is vital for organizations aiming to maximize revenue, especially when supporting safety net services that serve low-income and newly insured individuals.
The Illinois Public Health Association (IPHA) has a proven track record in supporting local health entities through the core components of third-party billing, including credentialing, contracting, coding, billing, electronic medical record (EMR) implementation, and revenue cycle management (RCM). Over the past decade, their technical assistance has generated more than $40 million in new revenue for essential public health services across Illinois. Notably, their efforts in 2020 earned recognition from the Centers for Disease Control and Prevention (CDC) as a Billing Project Success Story—a distinction awarded to only six projects nationwide.
For further insights into healthcare billing, it is beneficial to explore the role of data in transforming healthcare, which highlights how advanced data management enhances billing accuracy and efficiency.
Community-based organizations (CBOs) are especially pivotal in expanding healthcare access under Illinois’ 1115 Waiver. However, many lack the internal expertise or funding to engage in third-party billing, often relying solely on grants. To address this gap, IPHA has collaborated with Medical Revenue Cycle Specialists (MRCS) to develop a comprehensive, free playbook designed to guide CBOs through establishing billing processes and revenue cycle management (RCM). This resource offers practical advice on provider credentialing, payer contracting, medical coding, and fee schedules, helping organizations become more self-sufficient and less dependent on grant funding.
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Implementing effective billing systems requires attention to numerous details. For example, understanding the ethics and utility of artificial intelligence in patient care is increasingly relevant as automation and AI tools streamline billing and administrative functions. Additionally, when developing healthcare applications, organizations should be mindful of the seven critical considerations to ensure compliance, security, and usability.
IPHA also offers a series of webinars that cover a broad spectrum of topics relevant to third-party billing. Past sessions include strategies for denial management, understanding new Medicaid coverage policies, and leveraging programs like 340B to improve health outcomes for underserved groups. These educational resources are invaluable for staff seeking to stay current with evolving billing practices and policies.
Regional forums hosted by IPHA facilitate direct engagement between providers, payers, and policymakers. During these meetings, participants discuss billing challenges, share best practices, and strengthen relationships with Medicaid managed care organizations (MCOs). Facilitated by experienced professionals, these events help organizations navigate the financial landscape of public health services more effectively.
In summary, empowering local health organizations through education, strategic planning, and supportive resources is key to successful third-party billing. By embracing these strategies, public health entities can secure sustainable funding streams, expand service delivery, and better serve their communities.
For more guidance on establishing robust billing processes, visit the healthcare revenue cycle management resource, which offers valuable tips for developing effective healthcare applications and billing systems.