Billing Better in CalAIM
How to Improve Reimbursement for Enhanced Care Management and Community Support
Enhanced Care Management (ECM) and Community Supports are core components of CalAIM, a multiyear initiative led by the California Department of Health Care Services (DHCS) that take a person-centered approach to social service delivery and care management for individuals with complex health and social needs. These services also require significant coordination between community-based organizations (CBOs), local and county entities, and Medi-Cal managed care plans (MCPs).
The nature of Medi-Cal managed care billing, which requires confirmation of beneficiary enrollment in an MCP, authorization from the MCP, submission of claims or invoices, and tracking and correcting errors on claims or invoices before payment, results in complex billing protocols. Navigating this complex process is a barrier to entry for new providers and poses ongoing challenges for many existing contracted ECM and Community Supports providers.
To better understand the situation facing ECM and Community Supports providers and identify potential solutions, Aurrera Health Group conducted a series of stakeholder interviews with health plan representatives, county providers, CBOs, and MCP and provider associations. This issue brief outlines key challenges with each step of the billing process and technological and process-oriented recommendations for addressing them. Recommendations reflect potential strategies that could be implemented by DHCS, MCPs, and providers in the current delivery system.