Tribunus Health and CHIP of Roanoke Valley

Executive Summary

Tribunus Health partnered with Child Health Investment Partnership (CHIP) of Roanoke Valley to optimize their healthcare reimbursement and expand the services for which they receive compensation from payers. This collaboration resulted in significant financial improvements, enhanced service delivery and increased capacity to care for low-income families in Virginia.

Background

CHIP of Roanoke Valley is a non-profit organization providing early childhood home visiting services to Medicaid-eligible children and their families in several Virginia counties. They offer home comprehensive healthcare coordination, family strengthening services, mental health counseling, and kindergarten readiness programs.

Challenges

CHIP of Roanoke Valley faced numerous challenges in navigating the complex healthcare reimbursement landscape:

1. Stagnant Reimbursement Rates: Despite years of dedicated service, CHIP had not seen rate increases in many of their long-standing contracts. This stagnation threatened their ability to maintain competitive wages for their staff and expand services to meet community needs.
2. Incorrect Reimbursement: A critical issue arose with one key payer which was only reimbursing CHIP for children up to age three, despite CHIP’s services extending to kindergarten entry. This gap in coverage meant CHIP was providing unreimbursed care for a significant portion of their client base.
3. Payer Merger Confusion: The merger of 2 payers created a whirlwind of uncertainty. CHIP was left in the dark about how this consolidation would effect their billing processes, authorization procedures, and the continuity of care for their clients.
4. Network Inclusion Struggles: Despite their vital role in the community, CHIP faced persistent difficulties obtaining in-network status with major insurers. This exclusion limited their ability to serve families and receive proper reimbursement for their services.
5. Payer Lack of Awareness: CHIP’s team, while experts in providing care, lacked the specialized knowledge needed to navigate the intricacies of healthcare contracts and payer speak. Payers did not understand the services provided by CHIP and were content simply ignoring CHIP’s service and contracting requests.

These challenges weren’t just financial hurdles; they threatened CHIP’s ability to fulfill its mission of serving Virginia’s most vulnerable families. The organization needed a partner who could not only address these issues but also empower them with the knowledge and tools to thrive.

Tribunus Health’s Approach

Recognizing the unique challenges faced by CHIP, Tribunus Health utilized a comprehensive, collaborative approach:

• In-Depth Contract Analysis and Strategic Negotiation: Tribunus Health began by meticulously reviewing all of CHIP’s existing contracts. We identified outdated terms, unfavorable conditions, and missed opportunities for reimbursement. Armed with this knowledge, Tribunus Health initiated strategic negotiations with payers, advocating for fair rates that reflected the true value of CHIP’s services.
• Proactive Payer Relations Management: Understanding that many of CHIP’s challenges stemmed from miscommunication and misunderstanding with payers, Tribunus Health assumed the role of intermediary. We established direct lines of communication with key decision-makers at the insurance companies, effectively articulating CHIP’s unique role and value proposition.
• Comprehensive Billing Optimization: Tribunus Health examined CHIP’s billing practices. They identified numerous services that were being provided but not billed, and others that were undervalued. We then implemented a systematic approach to optimize CHIP’s billing, ensuring that every eligible service was properly coded and charged.
• Regulatory Compliance and Strategic Advocacy: Leveraging our deep understanding of Medicaid regulations and payer contracts, Tribunus Health helped CHIP navigate complex regulatory requirements. They also engaged with state agencies, including the Department of Medical Assistance Services (DMAS), to advocate for CHIP’s interests and ensure their services were properly recognized within the Medicaid framework.
• Educational Support and Ongoing Guidance: To ensure CHIP’s enduring success, we collaborated on guidelines aimed at further empowering their team in areas of contract interpretation and insurance company negotiations. This allows CHIP to uphold and expand upon the initial advancements made by Tribunus Health.

Throughout this process, the Tribunus Health team maintained a collaborative partnership with CHIP, ensuring that every step aligned with the organization s mission and values.

Throughout this process, the Tribunus Health team maintained a collaborative partnership with CHIP, ensuring that every step aligned with the organization’s mission and values.”

– Rachel Hopkins, CEO CHIP of Roanoke Valley

Results

The partnership between Tribunus Health and CHIP of Roanoke Valley yielded transformative results:

Substantial Revenue Increase: Between July-August 2023 to July-August 2024, CHIP saw are markable 60% increase in revenue. This boost came primarily from optimizing billing practices and securing reimbursement for previously unbilled services, rather than from rate increases. This additional revenue allowed CHIP to reinvest in their programs and staff, enhancing their ability to serve the community.

Resolution of Long-Standing Reimbursement Issues: One of the most significant wins was the resolution of a particular payer issue. Tribunus Health discovered that the payer had inaccurately configured CHIP in their system, leading to several years of claims under and nonpayment. Through persistent advocacy and negotiation, our team coached CHIP into securing a $182,000 settlement for backdated claims, covering services provided over several years.

Expanded Service Billing: Tribunus Health helped CHIP identify and start billing for numerous services they were already providing but not charging to payers. This included critical services like asthma education and dental varnish application. By capturing these billable services, CHIP not only increased their revenue but also gained recognition for the full scope of care they provide.

Improved Payer Relationships: Through Tribunus Health’s intervention, CHIP established stronger, more productive relationships with key payers. The confusion surrounding the payers merger was clarified, ensuring smooth transitions for billing and patient care. Additionally, progress was made in discussions with multiple payers about network inclusion, opening doors that had long been closed.

Enhanced Organizational Capacity: Beyond the financial improvements, CHIP’s team gained valuable knowledge and skills. They now have a deeper understanding of healthcare reimbursement processes, contract negotiation strategies, and the value of their services in the healthcare market. This newfound expertise positions them for sustained success and growth.

Maintained Clinical Excellence: Throughout this period of financial and administrative improvement, CHIP maintained and even enhanced their clinical outcomes. They continued to outperform Virginia MCO averages in key HEDIS metrics:

• Postpartum Care: 78% (CHIP) vs. 68% (VA MCO Average)
• Well-Child Combo 3 Immunizations: 75% (CHIP) vs. 60% (VA MCO Average)
• Six or More Well-Child Visits in First 15 Months: 73% (CHIP) vs. 63% (VA MCO Average)

These metrics underscore that the focus on financial optimization did not come at the expense of quality care. Instead, it enhanced CHIP’s ability to deliver exceptional services to their community.

Strengthened Community Impact: With improved financial health and optimized operations, CHIP was better positioned to address the needs of their community. They were able to reduce their waitlist and explore opportunities for program expansion, directly benefiting vulnerable families in Virginia.

The partnership between Tribunus Health and CHIP of Roanoke Valley demonstrates the profound impact that expert guidance and strategic optimization can have on a healthcare organization. By addressing financial and administrative challenges, Tribunus enabled CHIP to focus on what they do best: providing high-quality, compassionate care to those who need it most.

Conclusion

The partnership between Tribunus Health and CHIP of Roanoke Valley demonstrates the power of expert guidance in healthcare reimbursement. By optimizing billing practices, negotiating contracts, and advocating for the organization, Tribunus Health has helped CHIP significantly increase their revenue, expand their services, and ultimately provide better care to more members of vulnerable populations in Virginia.

About Tribunus Health

Tribunus Health specializes in healthcare reimbursement optimization, contract negotiations, and regulatory compliance. With decades of experience in Medicaid MCO contracts and Requests For Proposals, Tribunus Health helps healthcare providers maximize their reimbursement while improving their ability to serve their communities.