Social Care Networks

One concept that is being put to the test is the idea of Social Care Networks which aims to provide a path for non-medical services to be reimbursed by Managed Care Organizations (MCO’s) so healthcare providers can focus on improving the lives of the individuals they serve outside of a clinical setting. Historically, individuals who have access to a stable home life, transportation, and education on self-care like nutrition respond better to services in a facility and are more likely to maintain a healthy lifestyle on their own. This substantially decreases the risk of severe medical conditions like diabetes, liver failure, heart related problems, etc. and reduces frequent hospitalizations as well as complex surgeries.

CMS recently approved the New York State 1115 Waiver In New York which includes the establishment of Social Care Networks (SCNs) across the State. Through a competitive selection process, Social Care Networks will be chosen to team up with regional Community Based Organizations (CBOs), healthcare providers, and other community advocacy organizations to begin providing these Health Related Social Needs (HRSN) to individuals who qualify via the SCN screening process.

While this is very exciting news, it’s also a huge undertaking which will require relationships with lots of Community Based Organizations (CBOs), new staff, and technology to manage the process.

Millin: The financial office extension for Social Care Networks (SCNs)

Millin has been at the forefront of NY State Health & Human Services billing process for over 40 years. It has all the necessary tools, expertise, and experience to assist Social Care Networks (SCNs) ensure a smooth revenue cycle management implementation and consistent solid revenue and cash flow.

The Social Care Networks will need to focus on a multitude of items simultaneously:

• Staffing up for outreach
• Contracting with Community Based Organizations (CBOs)
• Contracting with Managed Care Organizations (MCOs)
• Implementing a referral and care management system
• And so much more….

Rest assured Millin will take care of the financial lifeline of Social Care Networks!

The MillinPro system will play a critical role on four fronts:

1. The system’s rules engine will be uniquely configured for the new reimbursable services & goods as well as ensure it has all nuances each payer requires for claim submissions. In our experience this can vary significantly from payer to payer, especially for new programs. Our business analysts keep track of all regulatory/payer changes and update the rules engine accordingly and in a timely manner.
 
2. The MillinPro system has a CBO facing portal which is updated in real time. This ensures full transparency between Community Based Organizations (CBOs) and Social Care Networks (SCNs). The Social Care Networks (SCNs) can provide Community Based Organizations (CBOs) access to the claims journey; from submission to the payer -> to the payers payment response -> to the payment from the SCN to the CBO. Having these capabilities builds trust between the SCNs and CBOs. Such functionality also significantly reduces the number of calls and emails between the CBOs and SCNs.
 
3. Thanks to our robust reporting module, Millin will be able to create the reports necessary for the Social Care Networks (SCNs) and more importantly ensure they are accurate. While this may seem like a given, It’s one of the top three complaints we hear from clients that choose to switch from a competing vendor to MillinPro. As result-based outcomes rely on data and analytics to show patterns and trends in performance, being able to track your Health Related Social Needs (HRSNs), claims, and revenue across all payers and across all CBOs is crucial in determining the effectiveness and financial health of the Social Care Network (SCNs)s.
 
4. Millin’s integration capabilities with other systems is second to none. We are very agile ingesting data from other systems as well as transferring data from MillinPro into additional systems that need to communicate with each other.

Social Care Networks (SCNs) Outsourcing the billing process and revenue cycle management:

Services that will be eligible for Reimbursement

Under the proposed SCN guidelines, the HRSN services will be broken down into 3 major categories: Housing, Nutrition, and Transportation. The following breakdown represents just some of the non-medical care available through CBOs and healthcare providers that are eligible for reimbursement:

Understanding Revenue Cycle Management Within the Context of Social Care Networks

A key part of the revenue cycle management process for healthcare providers is the ability to have full transparency into the lifecycle of your claims. Where your claims are in the pipeline, what’s been paid, what’s outstanding, what’s been denied, etc. will give you the full picture of the success and shortcomings in your billing cycle and give you a more detailed picture of your revenue and cash flow. This will be especially important as the Social Care Networks (SCNs) introduce another level of tracking transactions. With the introduction of potentially hundreds of CBOs under one Social Care Network (SCN) exchanging client information, HRSN data, and revenue, having a system that can provide insight and real-time data at a detailed and aggregate level, will become crucial to managing a successful SCN.

Millin on the other hand is configured specifically to handle this level of complexity. Having years of experience dealing with about 20 different managed care payors in NY means our MillinPro software is already built to provide tracking, analysis, and reporting across a large network of payors, each with their own specific billing rules and regulations. The adoption of these new HRSN services won’t pose a heavy lift for Millin as we already have whole departments and internal industry experts on standby ready to configure the new billing requirements in MillinPro.

Additionally, the inclusion of a screening process prior to an individual’s admittance into the SCN will be a core focus of the launch of HRSN services through the CBOs. Every member of the Social Care Network will be screened and this data is crucial for determining and tracking social risk factors and demographic data. This will ultimately be the authoritative source in figuring out who is eligible for these services and in what capacity. Accurate demographic and screening information that can be shared with the SHIN-NY in real-time will lead help with the Statewide aggregation of data. Over time, this data will be used to enhance the quality of care and services provided to each individual.

Why your Billing and RCM Vendor matters

Who the Social Care Networks select as their RCM vendor will be crucial to ensuring data integrity and transparency in the billing process. Millin has been configured to handle Medicaid, Medicare, MCO and commercial payors for behavioral health and IDD services. Our rules-engine is updated continuously as payor rules and regulations are everchanging. And as most people suspect, these first few years of the SCN will likely see constant changes in billing guidance and reimbursement.

The Social Care Networks will consist of Medicaid providers and contain up to dozens of CBOs in their network in some instances. Although the SCN will be responsible for overseeing program eligibility overall progress across the network of providers, it will be up to the CBOs to provide the HRSN services and bill, track and report on claims for all services and all individuals at their respective facilities. The CBOs will generate claims and kick them up to the SCN who will be responsible for submitting the HRSN claims or encounters. The MCOs will play a vital role in this as they will be responsible for processing the claims and paying the Social Care Networks directly.

Although it’s yet to be seen what the rates and reimbursement will look like for these services, the State has put an emphasis on being able to track, monitor, evaluate and embed these payments into a premium at a later point down the road. There are a lot of moving parts and a lot of entities exchanging transactions and this is where Millin can provide value – this is where an RCM software focused specifically on the tracking and reporting of claims across a network of payors and CBOs plays a vital role in determining the financial health of these SCNs over time.

The Goal and VBP

The SCN will not pay the CBOs on an at-risk basis. The CBO is paid on a fee-for-service basis with no risk involved. Over time, which could be a few years, the goal is to shift the focus to a value-based payment level of care between the plans and the SCN as the industry continues to innovate and test out new delivery care models.

VBP is the future and this is why there is such an emphasis on good data and a heavy first-year focus on screening. Screening will dictate eligibility for services and if the right individuals are receiving the right services, the State can much more effectively track the quality of care and the ongoing progress of the SCNs, the CBOs and the individuals receiving HRSN services.

Why Millin

Navigating the revenue cycle in the context of social care networks presents unique challenges, but with the right RCM software, these challenges can be transformed into opportunities for growth and streamlined operations. By investing in specialized solutions, like Millin, designed for the health and human service sector, organizations can unlock the full potential of their financial processes and provide even better care to their communities. Get in touch with us to learn how Millin can team up with you to become a trusted partner in financial operation and overall RCM efficiency as we look to a new system of care.