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Presenter outlines surge in claims processing; county recorded over 47,000 claims in 2024
Summary
Department staff told the Winnebago County Human Services Board that claims processed rose to more than 47,000 in 2024, generating over $6 million in revenue and growing roughly 11% annually; presenters described LUNA EHR workflows, denial drivers and a new GainWell requirement for CLTS billing.
The Winnebago County Human Services Board heard a detailed presentation on claims processing Feb. 23, with department staff saying the Human Services Department processed "over 47,000 claims" in 2024 and expects the total to exceed 50,000 in 2025.
Presenter (department staff) told the board that medical‑assistance billing accounts for the largest share of revenue—"well over $6,000,000" in 2024—and that roughly 75% of the department's billings derive from medical‑assistance programs. The presenter said claim volumes are rising at about an 11% annual rate and that a small claims team (described in the meeting as "about 2.5 staff people") handles the workload.
The presentation described the department's LUNA electronic health record, which populates the HCFA 1500 (CMS‑1500) claim form. "When we have a staff person who is seeing someone with a billable service, they will go into Luna, enter a contact note," the presenter said, explaining that demographic information, diagnosis codes, service codes and visit duration feed the claim form used for insurer submissions.
Board members pressed staff on denials and collections. Presenter said denials commonly stem from timely‑filing issues and diagnosis/code mismatches, and that the finance team reviews remittance advices to identify fixable errors. "When I look at revenue every month, almost every month, I'm seeing additional revenue because we've gone through this process," the presenter said.
The presenter also described a 2025 change affecting the Children's Long‑Term Support (CLTS) program: the state has required the department to use GainWell for CLTS billing, with a 365‑day timely‑filing rule for that program and prior‑authorization requirements for services.
Board members asked how many distinct clients the claims represent; staff said the department records roughly 80,000 visits per year but does not have a ready unduplicated client count and offered to return with that breakdown. Staff also confirmed that some insurers—particularly out‑of‑state or uncommon commercial payers—often contribute little or no reimbursement, while Medicaid and family‑care payers tend to be more reliable.
The presenter said the department performs quarterly reviews of billed insurers and maintains one staff member responsible for credentialing clinicians so payers will accept claims. Staff emphasized they generally do not pursue billing individuals directly when a one‑off insurer denies a claim and that fee‑assessment and poverty‑level rules protect clients from unaffordable bills. For example, the department uses a 300% federal‑poverty threshold in its ability‑to‑pay calculations.
The board requested a follow‑up: a top‑10 list of the services by volume and revenue, which staff agreed to provide at a later meeting.
The presentation occurred during the department's regular program reports; no formal action was taken on the claims presentation itself.
