3 Ways to Handle the Medi-Cal Managed Care and IPA Maze to avoid Insurance Denials
California has the highest percentage of population covered by HMOs and IPAs, including capitated plans play a big role. California Medicaid (Medi-Cal) has a significant market share and the covered population has the option to opt for Managed Care Plans offered by private payers. While all this has benefitted patients by reducing their out-of-pocket cost, Providers have been burdened with complex billing issues and denied claims etc. due to patients switching plans, sometimes between episodes of care.
Medi-Cal beneficiaries in all 58 California counties have Managed Care Plans (DHCA.ca.gov 1/1/2020)
IPA coverage has forever been a pain point for CA Providers.
By participating as providers registered with multiple IPAs, they can expand their client base, lower expenses, and simplify life as independent providers. Along with the pluses comes one rough negative mentioned above: unstable assurance of payment.
The repercussions of discovering your patient has flown the IPA coop means not only a potentially lost client, but lost income for all services provided after the switch. The only solution is to continually confirm IPA coverage, each month or prior to their next appointment. Traditional clearinghouses and patient eligibility verification vendors may provide HMO details, but none will capture the IPA for California Medicaid (Medi-Cal) or flag if a patient has recently switched IPAs. This is causing a host of issues: the piling of unpaid claims, lost time, money, and appointment slot that could otherwise be spent on a paying client, and no actionable method to determine if you need to obtain prior authorization.
Verify and Compare IPA Coverage
Available in Batch Processing and Individual Patient Verification
Confirm Coverage and determine responsible IPA
For Commercial Payers We verify each patient’s commercial payer benefits, detect if there is a HMO plan and provide IPA information in those cases.
For California Medicaid (Medi-Cal) We verify each patient’s Medi-Cal’s benefits and detect the Managed Care Organizations (the HMO Payer) along with the Plan Sponsor. Going one level deeper, we will then verify the HMO Payer to obtain the IPA details (with the Medi-Cal Subscriber ID.) Even when the Primary Payer is set to a Medi-Cal Managed Care Plan (like Molina or Health Net) pVerify has built unique business rules that will check the patient coverage directly with the Medi-Cal website or EDI system to see if the patient has Medicare Part A & B coverage or any other detail that is not shown by the managed care plan.
One step further… pVerify is the only Eligibility Service that provides IPA verification of benefits for all IPAs. Not only will pVerify determine the responsible IPA, we will provide IPA active status along with the Capitation details (by logging into the IPA’s website directly.)
Medical Group vs. IPA
An Independent Practice Association is an organization of physicians established to contract with third party payers. Not every doctor wants to sell their practice to a hospital or larger practice. An IPA allows physicians who aren’t one, combined corporate entity, to enjoy the benefits of a larger organization. They don’t have a legal relationship with one another, they remain independent practices.
IPA Conversion Detection
Understanding the unique challenges faced by CA-based Provider Groups (w.r.t Patient Eligibility & Benefits Verification) pVerify has develop an IPA Conversion Detection Solution, not available with any clearinghouse or other Eligibility Vendor. With its aim focused on California, pVerify worked to solve the day-old questions: “How can I trust the IPA coverage?” “What Payer do I need to obtain Prior Authorization From?” “Is their Medi-Cal HMO plan still active?” And so on.
In any HMO Plan, Members are allowed to change their PCP and also Medical Group / IPA without many restrictions (this can vary from Payer or Payer, but as a thumb-rule, this is allowed and accepted in HMO Model.) The basic workflow in determining coverage status is in the initial verification for new patients. For current patients additional IPA verifications are required to confirm they have not made an IPA changes. pVerify’s Conversion Detection, when provided with your patient’s current IPA listing, provides actionable identification and alerts for patients who have changed IPA Plans. Thus, preventing denials and allowing plenty of time for new prior authorization to be obtained.
IPA Conversion with pVerify is detected by taking the responsible IPA (described in Solution #1) and comparing it to the current IPA on file in your EMR/PM. Processed overnight in our Batch Excel Solution, pVerify’s Quality Control Team will review, compare, and highlight any changes. If needed they will also confirm the IPA Eligibility and Capitation Facility (by logging into the IPA’s website directly)
Deeper Customization for California IPAs
For some California Providers establishing the correct IPA is not enough. Providers contracted with an IPA that has a Capitation Limit, it can lead to profitability or large financial loss.
For example, if a PCP negotiates a fee of $750 per patient per year, with 500 patients enrolled with a specific HMO, the Provider will receive a max amount of $375,000. This sounds like a good deal until you factor in the cost of providing services. With this model, if the majority of patients used a minimum of services each year the Provider would make a profit. However, if services provided (including PCP visits, Specialists, Labs/Tests or Radiology) exceed $750 for a majority of the patients the Provider would be at a loss.
Determine Capitation Facility Information with pVerify Upon request, pVerify will verify IPA Coverage, obtain Capitation Facility information, and provide additional information found only by direct IPA website login.
- Simplifies bookkeeping
- Discourages excessive billing or more costly procedures
- Patients avoid unnecessary tests and procedures
- Providers may spend less time per patient
- Incentivizes providing fewer services
Informed Decisions Promote Positive Results
In order to make informed decisions in the upcoming steps of patient care verifying a patient’s Commercial or Medi-Cal coverage to confirm Active status and identity the HMO/Plan Sponsor and IPA details is essential. pVerify leads the medical insurance verification industry in its unique and complete solution from simply detecting unexpected IPA conversion to confirming IPA benefits and Capitation Facility. pVerify’s full Medi-Cal and IPA Solution allows for adequate planning and prioritizing when multiple ailments or issues are present, not to withhold patient care but to successfully navigate the profit/loss equation being an IPA contracted Provider presents.
pVerify® was founded in 2006 by a team of accomplished Healthcare Professionals with a singular focus: streamline the front-end patient insurance eligibility and benefit verification processes so as to not only improve the patient collections but also to reduce back-office denials. It’s HIPAA Complaint, SaaS offering includes robust set of REST APIs, fully-customizable Eligibility Portal and Mobile SDKs that have been powering mission-critical, front-end eligibility processes solutions for leading healthcare software companies as well as ambulatory practices in the healthcare sector.