IBHIS GO-LIVE - Claims & Revenue Risk Mitigation Topics

Now that there is an updated LACDMH IBHIS GO-LIVE roll-out schedule and there have been a couple of update calls, I have been getting a lot of questions around the topic of claiming, reimbursement timing, revenue risks, etc.

 I have been assisting my customers lately with IBHIS Risk Mitigation planning .... Here are some topics to consider for your GO-LIVE plans.


·    Cash flow advances – Agencies going live between July – September will receive 3 months’ cash flow advances; others will receive the standard cash flow advance stated in their DMH contract (I understand that this is being modified in the FY16-17 contract to allow for additional cash flow advances should there be any IBHIS claiming issues.)


·    Timeline Example – If your GO-LIVE date were January 2017, mid-fiscal year, then DMH assumes you will stop sending claims to the IS by the end November 2016 and hold all further claims until the end of December and no later than the claims cut-off on January 6^th. All claims ready for submission after your IS cut-off date of Nov 31^st, will be submitted to IBHIS as soon as you are ready, which is estimated to be in late December. Here is a rough timeline of what that might look like:

•        July 2016 – EHRS Vendor must be ready for IBHIS, with most up to date Client Web Services (CWS) and 837/835 changes.

•        August 2016 – check on TPA modification request with DMH / ACHSA. (There is a pending request to modify the TPA agreement to be more mutual, and to remove some of the high risk terms for Legal Entities (LE))

•        Sept. 2016 – LE staff begin preparedness for IBHIS.... PRM updates, sign TPA, Vendor readiness, etc.

•        Nov. 2016 – LE's final push to have all claims submitted to the IS. CWS GO-LIVE, make client data updates in IBHIS using CWS. (Some vendors are doing this for their customers with bathing, others require lots of key strokes by LE staff, be sure you plan staffing time for this!)

•        *Nov. 31^st, LE's IS cutoff – last day to submit new claims using the IS.

•        Dec. 1^st thru approx. Dec. 25^th – HOLD all new claims; continue PRM and CWS updates; work with DMH to validate initial batch of IBHIS claims (on paper); DMH will create MCA estimates and set amounts for P-Auth codes (LE and DMH to agree on P-Auth amounts & MCA buffer %!). 

•        **Approx. Dec. 26^th – IBHIS Claims GO-LIVE, begin submitting new claims in IBHIS;

•        Jan. 6^th – last day to submit IBHIS pending claims for next month’s reimbursement check.

•        Dec 2017 – Current IS shut-down date.

*Dec. and beyond - You will continue working previously submitted IS claims using the IS, i.e. voids, replacements, etc. until IS shut down.

       ** Your IBHIS Claims GO-LIVE can be sooner if ready (once DMH has issued P-Auths), or later. As long as you submit all pending claims before the Jan. 6^th cut-off, you should have no gap in cash flow.

Note: The standard LACDMH IBHIS timeline assumes agencies will not miss any claims cut-off dates for monthly reimbursement, and therefore, should not need additional cash advances for IBHIS reasons. This may not be the case for everyone, you must map our your timeline and determine risks and plan mitigation if you miss these dates!


Here are some ways to mitigate:

•      DMH will allow LE’s to request a MCA “buffer”, a percentage above the MCA for the fiscal year, to avoid unnecessary denials. E.g. If LE voids a group of IS claims after the IBHIS GO-LIVE and does not replace them in the IS, then you may see claims incorrectly denied in IBHIS at the end of the fiscal year, unless DMH moves the voided claims’ funds from the IS to IBHIS P-Auths. Another example would be if IS claims are denied by Medi-Cal several months after your IBHIS GO-LIVE, and you prefer to re-issue these claims using IBHIS, then you will need these funds moved from the IS to IBHIS P-Auths to avoid these being denied for lack of funds toward the end of the fiscal year. The “buffer” will give you some cushion in IBHIS to avoid denials for lack of funding, however, you will need to carefully track your utilization to avoid over spending to plan.
  
  Question for DMH: How will DMH handle denied claims in IBHIS and the P-Auth amounts? e.g. Will DMH deduct the Medi-Cal fund amounts each time a claim is forwarded to the State, or wait until they have a response from the State? If the former, then will DMH add back the IBHIS denied claim amounts to your IBHIS P-Auths as soon as a denial comes from the State?
  
•      Maximum Contract Allowance (MCA) & P-Auth amounts – During the above claims HOLD time, DMH will calculate the LE’s remaining funding by plan based on their IS data (Maximum Contract Allowance - MCA). DMH will issue the IBHIS P-Auth codes that reflect their remaining funding by plan.  In IBHIS, any claims sent once the plan’s P-Auth code reflects that funding has been depleted, will be denied real-time. If the LE’s MCA is being shared in FY1617 between the IS and IBHIS, it is critical that the LE create their own estimate of their remaining MCA by fund to compare to the DMH MCA calculations prior to issuing P-Auth codes.
  
•      Claims validation just prior to GO-LIVE – DMH will provide a claims validation (paper Excel based method) just prior to your GO-LIVE, which is voluntary. I recommend you take advantage of this step. You will need to complete a DMH Excel template with all claims data for the initial set of claims you intend to submit to IBHIS in your first go-live month, and DMH staff will review the claims data for any issues that would cause rejections of denials. This will assure a smoother GO-LIVE. For large LE’s I recommend you take this approach for 2 months if you find significant changes needed in the first month validated.

As always, hope this provides some clarity and guidance to you! Call me if you need help.