Community service agencies provide a safety net for individuals who need additional care but may not have the resources to afford it. As of 2023, community health centers served over 31 million patients. One of the main ways that community service agencies can provide case management, in-home support, medically-necessary diets, and more is through Medicaid. By accepting this government-funded insurance, community-based organizations can provide more care to people in need.
However, anyone who works with Medicaid understands the complexity behind it. With changing billing requirements from the federal government and states, it can be difficult to file claims correctly and receive compensation.
In this article, we'll break down the struggles that CBOs (community-based organizations) face with Medicaid billing in particular, and how you can utilize software like PlanStreet to streamline the process.
Why Community Service Agencies Struggle With Medicaid Billing: Hospitals vs. CBOs
While medicaid billing in hospitals can still be a challenge, there are better systems in place to handle the complicated workflows. Hospitals are seen as a traditional Medicaid provider, having taken the coverage for nearly 60 years. This allowed for plenty of time to create tried-and-true billing practices. Additionally, the codes used for their services remain fairly unchanged.
However, HCBS (home and community based services) did not join until 1983 when Congress added section 1915(c) to the Social Security Act. The need for community agencies skyrocketed when the Affordable Care Act was passed in 2014, expanding eligibility for people under 65 living below 133% of the federal poverty level. This group needs a wide variety of services, including housing, food, case management, and workforce. With such a wide umbrella of offerings, CBOs have to juggle different documentation requirements, making billing much more challenging and leading to Medicaid reimbursement issues.
Additionally, hospitals typically have specialized staff to handle Medicaid billing, including:
- Insurance verifiers
- Billing and claims specialists
- Collections and AR specialists
- Coding auditors
- Billing coordinators
Community service agencies are typically grant-funded organizations, so they use grant-style accounting with smaller teams. Oftentimes, they don't have the same experience billing for Medicaid, so the lengthy Medicaid billing process competes with serving clients.
Community Service Agency Medicaid Billing Challenges: Solved by Software
To bridge the Medicaid gap, community services agencies need to use Medicaid billing software that folds seamlessly into their grant and case management workflows. Software like PlanStreet is made for community service agencies, with medicaid billing software built alongside the other critical internal processes required to run daily operations. Here's how PlanStreet solves the typical Medicaid billing challenges for nonprofits and state agencies.
Lack of Clarity in Policy and Coverage
While Medicare is a federal initiative, it is carried out by each state. How services are covered, for whom, and under what conditions changes depending on where you live. These can be difficult to track, with annual changes making CBOs feel like the rug is pulled out from under them.
Maybe you can relate to some of these policy challenges:
- Navigating if whether an activity is billable or grant-funded
- Figuring out when you need a Federally Qualified Health Center (FQHC) subcontractor
- Deciphering what licensure is required for each service your CBO offers
- Understanding client eligibility before providing services
The PlanStreet Difference: Grant and Medicaid Tracking
PlanStreet creates a single source of truth for all client information, making it one of the best software solutions for Medicaid billing problems. We update our software based on the most recent state and federal requirements, ensuring that you always have the most up-to-date compliance on hand. Additionally, our grant tracking software makes it easy to match funding to grants, ensuring that you always know when to bill for Medicaid.
Additionally, our real-time eligibility checks allow your team to quickly see if a client has coverage for a specific service, reducing claim denials.
Struggle to Code and Build Claims Accurately
Community-based Medicaid billing has its own language. Staff must be up-to-date on the nuances of the billing requirements, which include:
- Current Procedural Technology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes: Identifies all the items and services included within certain designated health services (DHS) categories.
- CPT/HCPCS Modifiers: Provides additional information about a service, including the body part, multiple procedures, or unique circumstances.
- Provider Roles: CBOs must navigate the differences between rendering, ordering, and billing providers
- Place-of-Service Codes
These codes offer a steep learning curve for billing. Many CBOs struggle with repeated denials because of missing provider identifiers or incorrect code combinations.
The PlanStreet Difference: Custom Billing Rules
PlanStreet's invoicing and billing software allows you to create custom billing rules. Our Medicaid billing automation software:
- Stores payer‑specific billing rules: Once a user selects the payer and service, the correct procedure codes, units, modifiers, and place of service are applied automatically to the claim. This reduces common Medicaid errors.
- Maps services to billing and service increments: A staff document services within the client's case file, and PlanStreet matches those entries to the right billable service and increment.
- Automates EDI 837 claim files: PlanStreet generates EDI 837 claim files from service data, filling in required fields such as member identifiers, provider NPIs, diagnosis, and service lines according to each payer's format.
Extensive Documentation Demands Lead to Denials
CBO documentation doesn't always mirror what's required for Medicaid. In CBOs, it's critical to document progress and create a narrative that shows a client's improvement. This is what grant funders typically care about. However, Medicaid requires more activities aligned with their billing requirements, including:
- Accurate time and units
- Links to covered diagnoses
- Care plan goals
A CBO must prove that its clients are eligible for Medicaid, which requires additional screening, intake, and verification steps that they may not be used to. For example, maternity programs are only for pregnant or postpartum individuals within a certain time frame. This must be documented in a specific way for the services to be approved.
The PlanStreet Difference: Linked and Customizable Case Notes
With PlanStreet's document builder, you can create specific case note formats with required fields to ensure case managers and other service providers always collect the information needed for the claim. These case notes are then stored in the same platform as your Medicaid Billing software, making it easy to attach each required datapoint to the claim when it's time to bill. This helps reduce Medicaid claim denials because the information you need to fill out the paperwork correctly is always at your fingertips.
Outdated Paperwork Methods Eat up Billable Hours
Many CBOs make the most with very little funding, meaning that they can get behind on more modern techniques. Many use spreadsheets, paper forms for intake, and pen and paper note-taking. These outdated systems make it very difficult to submit a Medicaid claim.
However, when CBOs try to make the switch to a Medicaid billing software, many utilize a traditional electronic health record (EHR) that's too complicated and expensive for their needs.
The PlantStreet Difference: A User-Friendly Workflow
PlanStreet combines case management software and Medicaid billing, creating one platform that handles all of the paperwork required to run a CBO. With different use cases including:
- Workforce Development
- Affordable Housing
- Behavioral Health
- Food Banks and Pantries
- Child Advocacy Centers
When signing up for PlanStreet, we help you build out the platform that meets the specific needs of your organization. No matter how many different services you offer, we can create a case management and Medicaid billing system that keeps you compliant.
Struggle to Complete the Medicaid Revenue Cycle Promptly
While the windows for the Medicaid revenue cycle aren't set in stone, it's best to charge for services within a few days to ensure nothing slips through the cracks. The Medicaid revenue cycle usually goes as follows:
- Pre-service: Schedule patients, registration, Medicaid eligibility verification, referral/prior authorization checks, and capture consents and demographics.
- During service: Document services, assign codes, charge entry, and build clean claims.
- Post-service: Post payments, reconcile payments against expected amounts, work denials and underpayments, appeal when appropriate, and collect patient responsibility.
However, smaller agencies often struggle with delayed billing due to challenges such as provider enrollment, tracking prior authorizations, managing appeals, and fixing denials.
The PlantStreet Difference: Claims-Lifecycle Dashboards
PlanStreet offers a built-in analytics software that lets your team see the entire claims lifecycle at one glance. See every client's claims from submission to reconciliation. This helps your team spot any hurdles that would create a denial, and you can fix them accordingly. Plus, with access to case management, your team can minimize duplicate data entry and keep cycles shorter.
Streamline Medicaid Billing for Community Service Agencies With PlanStreet
PlanStreet's Medicaid billing software simplifies the process so CBOs can do what they do best: provide life-saving services for their clients. By automating the most error‑prone steps, enforcing payer‑specific rules in the background, and tying billing directly to the work your teams already document, PlanStreet turns Medicaid from a constant fire‑drill into a predictable, repeatable process.
If your team is feeling stretched thin by the lengthy requirements of Medicaid billing, schedule a call with our experts to learn more about our time-saving platform today.