Medical Billing in Pennsylvania

What is specific to Pennsylvania

Pennsylvania Medical Assistance operates alongside HealthChoices managed care plans.

Pennsylvania’s Medicaid programme is PA Medical Assistance. Practices with a meaningful PA Medical Assistance mix usually need it worked as its own queue rather than mixed into commercial follow-up, because the submission path, the timely filing window and the appeal route are all different.

What a medical billing seat does in Pennsylvania

Aged accounts receivable called until they close, and denials read, appealed and tracked.

In Pennsylvania the queue that costs the most is PA Medical Assistance: 180 days from the date of service (original invoice); 365 days to resubmit, and a claim past that date is unpayable rather than late.

• Worklist worked from the difficult end, not the easy end
• Every call logged with the payer reference and the outcome
• Denials categorised so the same reason stops recurring
• Appeals written and submitted, not just re-bills
• Weekly written summary of what moved and what did not
• Worked during Pennsylvania business hours, not queued overnight

Most of the Pennsylvania work we see comes out of Philadelphia, Pittsburgh and Allentown, though nothing about a seat depends on where your office is — the queue is worked through your system, not from your building.

Pennsylvania borders 6 states, and practices near those lines almost always carry at least one out-of-state Medicaid enrollment. That is a separate portal, a separate filing window and a separate appeal route from PA Medical Assistance, and it is the queue that most often goes unworked because it belongs to nobody.

What Pennsylvania law gives you

45 days from receipt of a clean claim, with no electronic-vs-paper distinction — the same 45 days applies either way. Act 68 / 40 P.S. 991.2166, implemented at 31 Pa. Code 154.18. Interest is added to late clean claims and must itself be paid within 30 days of the claim payment.

Source.

PA Medical Assistance, in practice

Mandatory managed care. Physical HealthChoices is Pennsylvania's mandatory Medicaid managed care program, organized into five zones — Lehigh/Capital, Northeast, Northwest, Southeast and Southwest — with roughly four to five physical-health MCOs offered per zone; the distinct plans listed on the DHS MCO page are AmeriHealth Caritas (Pennsylvania and Northeast), Geisinger Health Plan, Jefferson Health Plans EverWell, Highmark Wholecare, Keystone First, UPMC for You, and UnitedHealthcare Community Plan (seven brands statewide, but a given practice only faces the subset serving its zone). Community HealthChoices is the separate mandatory managed care program for dual eligibles, older adults and adults with physical disabilities. Source

Pennsylvania workers' compensation pays on a Medicare-derived cap, not a stand-alone state fee schedule: 34 Pa. Code 127.101 provides that 'Generally, medical fees for services rendered under the act shall be capped at 113% of the Medicare reimbursement rate applicable in this Commonwealth under the Medicare Program for comparable services rendered.' Two operational consequences a biller must know: 'Medicare coinsurance and deductibles may not be used to reduce the allowable fee under the act,' and the cap binds every licensed provider treating an injured worker 'regardless of whether the health care provider participates in the Medicare Program' — so a non-Medicare practice still gets priced off Medicare rates. An insurer may not pay above the cap unless paying under a contract with a Secretary-of-Health-certified CCO. Source

On the commercial side the dominant Blue plan here trades as Pennsylvania is split among multiple Blue licensees rather than one statewide plan: Highmark Blue Cross Blue Shield / Highmark Blue Shield across western, north-central, north-eastern and central Pennsylvania and the Lehigh Valley, and Independence Blue Cross across the five south-eastern counties (Philadelphia, Bucks, Chester, Delaware, Montgomery). Highmark's Medicaid arm 'Highmark Wholecare' was directly verified as a HealthChoices MCO on the PA DHS site., which matters mainly because its portal and its appeal route are the ones your seat will spend the most time in. Source

How long you have to file a PA Medical Assistance claim

180 days from the date of service (original invoice); 365 days to resubmit, measured from the date the services were rendered. A rejected original claim or an adjustment must be received within 365 days of the date of service.

“A provider shall submit original or initial invoices to be received by the Department within a maximum of 180 days after the date the services were rendered or compensable items provided.” 55 Pa. Code § 1101.68 — Invoicing for services

A claim past that date is not late, it is unpayable, and no appeal recovers it. It is the one queue where a week of nobody working it is money that does not come back — which is the argument for working PA Medical Assistance as its own queue rather than mixing it into commercial follow-up. Every state’s limit is listed here.

Working Pennsylvania hours

Pennsylvania runs on Eastern time, 10 hours behind our floor in Rawalpindi. To be at a desk for your nine to five, the shift here runs 7pm to 3am, and 6pm to 2am once the clocks go forward. Pakistan does not observe daylight saving, so the shift moves on this side rather than yours.

That is the part that decides whether follow-up happens at all: a payer’s phone lines are open on Pennsylvania hours and nobody else’s.

What it costs in Pennsylvania

$1,700

Per seat, per month, in US dollars — $20,400 a year for one full-time person, forty hours a week, on Pennsylvania hours. No annual contract, no percentage of collections, no setup fee and no software to buy. Seat prices across all roles in Pennsylvania run $1,500 to $2,500; the full list is published.

That is the entire invoice. Run your own figures against a percentage vendor or a hire rather than take ours.

Getting started in Pennsylvania

About a week from a signed agreement to a person working your queue, and that week of training on your workflow is not billed on top. The work happens in your own system under a login you issue, so there is nothing to migrate and nothing to install. The week, step by step, and what is signed before anyone has access.

Questions