Smart Health Claims Saves and Captures State and Local Health Care Dollars

UMASS Vaccine Pharmacy and Reimbursement Program Counts on Smart Health Claims

Challenge:

The H1N1 Influenza pandemic of 2009 impacted Americans in every state, with an estimated 59 million contracting the virus, 265,000 requiring hospitalization, and several thousand losing their lives. In Massachusetts, hundreds were hospitalized and more than 30 died. Statewide, several dozen schools were also closed due to high rates of flu-related absenteeism on the part of staff, faculty and students.

Owing to the Federal government’s declaration of a public health emergency, vaccine was allocated to the states from available stockpiles, and state and local public health authorities, including local boards of health in Massachusetts, were called upon to conduct large-scale H1N1 and seasonal influenza vaccination clinics for their communities with no clear path for reimbursement.

Solution:

Motivated by the need to help relieve ongoing state and local financial strains illuminated by the H1N1 outbreak, the University of Massachusetts Medical School (UMASS) Center for Health Care Financing, in partnership with the Massachusetts Department of Public Health, initiated the Vaccine and Pharmacy Reimbursement Program to increase vaccination rates while providing financial support to public providers.

With the advent of the Vaccine and Pharmacy Reimbursement Program, UMASS sought a proven, secure, Web-based revenue cycle management solution, selecting SMART Health Claims for its robust yet flexible provider management, claims processing, payment reconciliation and reporting features. As part of the engagement, the SMART Health Claims team provided end-to-end implementation services, including Cloud Hosted deployment as well as functionality for online eligibility verification, EDI integration, and managed claims processing and billing for public and private payers.

UMASS now handles claims management and billing for 165+ providers, including school districts as well as hospitals, public health nurse organizations, hospices and others, throughout Massachusetts and in the States of Maine and New Hampshire. Supported by SMART Health Claims, the dedicated Vaccine and Pharmacy Reimbursement Program team bills more than 15 private insurance carriers in addition to MassHealth (the Commonwealth’s combined Medicaid and Children’s Health Insurance Program (CHIP)), other Medicaid, Medicare and Tricare for health care services supplied by public providers and then distributes the recaptured funds to the provider organizations.

Results:

To date, the UMASS Vaccine and Pharmacy Reimbursement Program has succeeded in capturing millions of dollars in payer reimbursements (more than $4 million in claims from 2017 to date alone), including from leading regional insurance companies, for public providers’ cost of purchased vaccines as well as immunization administration fees. This includes not only vaccinations related to the annual flu season, but also the cost and administration of childhood and adult immunizations recommended by the Advisory Committee on Immunization Practices (ACIP).

Verifiable success with the Vaccine and Pharmacy Reimbursement Program has led to UMASS’ extension as well as expansion of SMART Health Claims software and services to additionally support Massachusetts State Laboratory’s funds recapture for blood lead level and Sexually Transmitted Diseases and Infections (STD/STI) testing. State Lab services include full revenue cycle management along with direct-to-patient and third-party invoicing. The newer Laboratory Blood Lead Levels and STI programs have also seen nearly $1 million in claims.