ENCORE Medicaid Reimbursement
By automating the complex process of Medicaid encounter entry, tracking and billing, Spectrum K12 makes it cost effective and easy for school districts to manage the electronic claiming process in-house.
Spectrum K12’s web-based Encore Medicaid Reimbursement solution provides school districts with a complete package for maximizing Medicaid recovery with minimal resources. Encore Medicaid Reimbursement creates a completely documented audit trail to allow the practitioner, section chief, and internal or external auditors to work from the paid claim back to the servicing practitioner, and the underlying encounters containing appropriate presenting problem, progress notes, and other appropriate documentation in accordance with recognized state and district standards. The encounters can be further matched to the contents of the child’s clinical folder plus the appropriate prescribed IEP service lines and prescription information to assure IEP compliance in terms of Medicaid billable services.
Operating seamlessly with Encore Special Education, the Encore Medicaid Reimbursement solution produces electronic service tickets, applies billing rules, generates initial and replacement claims, electronically submits claims to the state Medicaid agency, and applies remittance advice—all in a “hands-free” operation that requires minimal time from district staff.
More Medicaid Recovery at a Lower Cost
Districts not billing for Medicaid-eligible services may be missing out on a significant source of revenue. Encore Medicaid Reimbursement eliminates the high fees associated with using a 3rd-party billing agent, ensuring more money is returned to the district. Replacing manual claiming procedures with intelligent, rule-driven software, Encore Medicaid Reimbursement increases the accuracy of claims billed and decreases missed billing opportunities—resulting in greater recovery amounts for the district.
Increased recovery rates offer districts an excellent return on their investment in the Encore Medicaid Reimbursement product. In the past three years, Spectrum K12 has billed more than $42 million in claims for its Medicaid billing clients with a claim approval rate of more than 97%.
Efficient Processing Requiring Minimal Resources
The highly-automated Encore Medicaid Reimbursement software eliminates district staff time typically dedicated to claiming, billing, and review, limiting it to only the small percentage of claims that are rejected and require further investigation. With an extremely high claims accuracy/approval rate that averages 97%, Encore Medicaid Reimbursement allow districts to manage the entire process with fewer resources than it takes to send billing out-of-house.
Automated claiming under district control allows for more frequent and rapid processing of claims. This reduces the risk of claims expiration, as well as the time it takes for the district to receive its approved funds. Submission of late encounters is seamlessly handled by generating replacement claims that result in a credit being issued for any original paid claims and the new claim amounts being approved in their place.
Complete Reporting and Audit Trail
Providing a clean and consistent audit trail—from billing claim, to service ticket, to IEP prescribed service line — Encore Medicaid Reimbursement recoveries are highly audit-defensible. Stored electronically in the system, documentation of service delivery and billing information is easily retrievable and reproducible at any time. The district can readily store information for as many years as needed.
Billing reports show the status of accepted/rejected service encounters, claims status, remittance advice, and student claims history. These and other reports make it easy to investigate unclaimed services and rejected claims, to reconcile claims advice, and monitor claiming trends in order to project future revenues or detect under-reporting of services.
Complete summary of Medicaid claim statistics
Spectrum K12’s Encore Medicaid Reimbursement state-of-the-art software can:
- produce HIPAA-compliant claims that are electronically submitted to the state Medicaid agency in accordance with individual state rules
- automatically convert recorded service encounters into appropriate billing codes
- automatically track and update student Medicaid eligibility information by exchanging Medicaid Eligibility Request and Response batch files with the state
- maintain a history of service rate changes as they occur with the effective Start and End Dates for each
- account for service rate changes as they occur
- increase the accuracy rate of claims billed by applying state defined maximum allowed units of service per day per service code per child
- electronically notify the billing clerk and/or other designees when a billing run has been completed, or any sort of processing anomaly has occurred
- flag any unbilled service encounters for further investigation
- automatically generate replacement claims to handle late submission of encounters, retroactive rate changes, and the voiding of encounters billed in error
- accommodate out-of-district/private school students and outside agency service providers
- process all electronic claim submissions, acknowledgements and remittance advice using state-standard formats and data elements
- provide reports which assist in claims management and highlight revenue opportunities
Transition Made Easy
Spectrum K12 provides services that provide districts the option to gradually transition Medicaid billing to an in-house function, or to immediately assume control of the entire IEP encounter entry and Medicaid billing process. With best practices experience in multiple states, Spectrum K12 can assist districts in maximizing their Medicaid recovery through a combination of software and services tailored to the district’s needs.
