Data Sheet: HealthEdge Source™ - Medi-Cal Reimbursement

HealthEdge Source's Medi-Cal Payment Integrity

HealthEdge Source's Medi-Cal solution offers a prospective payment integrity system designed to manage accurate and compliant pricing data, alleviating the administrative burden on health plans. With over a decade of experience supporting Medicaid in California, Source provides hands-off, automatic delivery of Medi-Cal policies every two weeks, ensuring your organization remains compliant without internal IT efforts.

Key Benefits and Features

• 10+ Years of Experience: Proven track record in providing Medicaid support to California clients.
• Comprehensive Medi-Cal Content: State-specific fee schedules and payment policies.
• Coverage across a wide range of facility and professional provider types.
• Automatic Policy Updates:D elivered bi-weekly by Source SMEs.
• Eliminates the need for internal IT involvement.
• Cloud-Supported Infrastructure and Single API: Enhances time-to-value with seamless integration.
• Customizable Fee Schedules and Payment Policies :Allows adjustments to meet complex payment arrangements.
• Enhanced Transparency: Improved audit processes and provider relations.

Expertise in California Medicaid (Medi-Cal)

Medi-Cal reimburses qualified medical expenses based on criteria set by California's Department of Health Care Services (DHCS) and the Federal Government. HealthEdge Source’s Payment Policy team consists of agile, specialized units including Medi-Cal subject matter experts, ensuring accurate and efficient policy implementation.

Real-Life Application Example

In the case of Orthopaedic Hospital v. Belshe, a settlement resulted in a 43.44% payment augmentation for services provided in California hospital outpatient departments. HealthEdge Source incorporates this rate increase into final reimbursements, offering users flexibility to adjust according to specific requirements, such as applying increases only to services without a rate change since June 2001, or using Medicare rates as a baseline for laboratory services.

Depth of Medi-Cal Content

• Support for All Medi-Cal Provider Types
• Multiple Surgery and Imaging Reductions
• E&M Procedure Reimbursement by Age
• Detailed Pricing for DME, Anesthesia, Vaccines, and More
• Special Modifiers and Adjustments:
  • AB 97 Professional Payment Reductions.
  • Orthopaedic Hospital v. Belshe Rate Increase.
  • Ambulance, Chiropractic, Audiological, and Respiratory Services.
• Comprehensive Medicaid Edits:
  • National Correct Coding Initiative (NCCI).
  • Medically Unlikely Edits (MUE).

Impact and Savings

The Centers for Medicare & Medicaid Services (CMS) estimates $132 billion in annual improper payments, with over 60% stemming from Medicaid. Source’s mission is to help clients pay claims accurately, quickly, and comprehensively, reducing inaccuracies and administrative costs.

By the Numbers

• 40% Reduction in Claims Needing Re-keying
• 5-8% Time Savings Over Previous Processes
• 25% Total Claims Identified with Inaccuracies
• $5 Savings Per Identified Claim from Improved Accuracy

Conclusion

Source's Medi-Cal payment integrity solution is essential for healthcare providers seeking accuracy, efficiency, and compliance in claim processing. To learn more about how Source can transform your payment integrity process, visit HealthEdge Solutions for Prospective Payment Integrity.