Financial Issues to Highlight When Launching a Care Coordination Program

Written by AMANDA ESTRINE, MBA

_________________________________________

A children's provider must consider an array of financial issues in order to optimize financial results when launching a care coordination program. Care coordination programs can yield a profit or, if not planned properly, produce losses. 

Below are some of the critical items that drive financial results.

Caseloads - A provider can bill Medicaid for outreach and engagement. Having a care coordinator call a client qualifies as an outreach service. This means that a care coordinator can have a much heavier caseload than a traditional case manager, who typically provides more face to face interactions with clients. A provider should plan for a range of cases per care coordinator, depending on the acuity scores of the consumers involved. This entails educating both your administrative and direct care staff about the nature of the contacts required and the differences between providing traditional case management and this new model of care. Incentives for care coordinators with the highest number of contacts may also encourage them to embrace heavier caseloads.

Acuity Scores - There is a sliding fee scale for Care Coordination. Each consumer is assigned an acuity score that reflects the level of care required and the rate for this consumer. It is important to track the range of acuity scores that consumers are being assigned to ensure that your care coordinators make targeted efforts to engage consumers with the highest scores and rates.

Tracking Claims - Billing for Care Coordination is complex. Some Health Homes bill managed care organizations directly and then pay providers. This makes it challenging to track claims and anticipate payment dates, adversely effecting your ability to provide accurate financial results to your Board of Directors and other key stakeholders. To mitigate this, a provider must designate operations and financial staff to track and manage care coordination claims. In addition, providers can experience long lag times between uploading claims and receiving payments. In some instances providers have reported 120 days or more before payments were received. A provider about to launch a care coordination program must consider this factor before launching this new service line.

Assessing Financial Results - In order to ensure that you are achieving your care coordination financial plan, it is imperative that you track your results. This entails monitoring the number of monthly referrals received, quality of the referrals, outreach and engagement rates, acuity scores, and claims denial rates. Also, the caseloads of each care coordinator and their billable units of service should also be tracked on a monthly basis to establish accountability and reward high-performing staff. If it is determined that you are not achieving the financial results anticipated, it is important to identify the source of the problem and correct it as quickly as possible before deficits develop.

---

Amanda Estrine, MBA, is the Director of Finance at SAE & Associates, where she creates financial plans and projections for SAE's clients in the behavioral health field, recently focusing on the development of financial plans for the launch of clients' Home & Community Based Services (HCBS) lines. Prior to SAE, she was the Director of Budgets at PSCH, a Human Services provider with over $100 million in programs for the developmentally disabled and the mentally ill.