DODD allows providers to hire billing agents. Hiring a billing agent can provide significant advantages for providers seeking to streamline their operations. Here are several reasons why using a billing agent is helpful:
- Monthly Cost and Service Hour Projections
- The MRC is used to project costs and service hours for each month within a 12-month waiver span. This allows providers to plan and bill based on anticipated service delivery, rather than only actual hours worked.
- Daily Billing Unit (DBU) and the 3% Margin
- Providers bill using a Daily Billing Unit (DBU), which is a flat daily rate calculated by dividing total Homemaker/Personal Care (HPC) and On-Site/On-Call costs by the number of service days in the month.
- If the actual service hours delivered are within 3% (plus or minus) of the projected hours, providers receive the full projected payment for the month. This margin accounts for small, routine fluctuations in service delivery.
- Reconciliation and Adjustments
- At the end of each month, providers must enter actual staffing hours and mark the month as complete in the Medicaid Service System (MSS).
- If actual hours are outside the 3% margin:
- Above 3%: Services delivered above projections are not reimbursed. Providers should review and adjust future projections.
- Below 3%: Overbilling is identified, and claims must be resubmitted for recoupment of overpayments.
- Settings Where MRC Applies
- MRC applies to agency-provided, shared Homemaker/Personal Care (HPC) settings.
- It does not apply to independent providers, Ohio Shared Living, or certain other arrangements.
- Exemptions and Special Cases
- If the calculated DBU exceeds Medicaid’s maximum reimbursement rate, providers (through the county board) can request an exemption for that month.
- During exemption months, providers must comply with Electronic Visit Verification (EVV) requirements.
- Best Practices for Providers
- Enter actual hours promptly and reconcile monthly.
- Communicate changes in schedules or service needs to the county board to ensure projections remain accurate
In summary:
The MRC streamlines billing by standardizing payments through the DBU, providing predictability for providers while ensuring accuracy through monthly reconciliation. Staying within the 3% margin is key to receiving full payment, and prompt communication and documentation are essential to avoid under- or overpayment.
For details, see Frequently Asked Questions, or reach out to us!
If you have questions, please Email Our Service Team.
