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Medicaid Eligibility: Winning Strategies in the Reform Era

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Medicaid Eligibility: Winning Strategies in the Reform Era


Tom Yoesle, Chief Executive Officer, Revenue Cycle Point Solutions
John Young, Senior Vice President, Medicaid Eligibility Operations

“Providers really have to sit down and look at that investment in technology that’s going to help them identify eligibility types... and also do that hard analysis by service line, diagnosis, by campus, by facility, etc.”

– Tom Yoesle | COO | Parallon, Revenue Cycle Point Solutions


Healthcare providers are facing higher numbers of Medicaid applicants and uninsured patients coming in to emergency departments as a result of changes to Medicaid eligibility programs and processes. In order for providers to build a winning Medicaid eligibility strategy, data is key.

From the provider perspective, changes to Medicaid eligibility—through healthcare reform and others factors— have resulted in increased patient volumes, which are challenging providers understanding of how the patient increase impacts operations and revenue, according to Tom Yoesle, chief operating officer of Parallon’s Revenue Cycle Point Solutions. “Once they figure it out, providers are then tasked with how to address what they’ve learned,” he added.

Healthcare providers who have worked through those issues and created successful Medicaid eligibility strategies use cutting-edge technology and processes to drive those strategies, said Yoesle and John Young, senior vice president of Medicaid Eligibility Operations for Parallon, a leading provider of healthcare business and operational services. These providers are ones that “got creative,” Young said.

Getting creative, however, doesn’t mean winging it. It means using your data to determine what your top challenges are and then using that data to build solutions to surmount them. Take, for example, a common top challenge: staffing. With Medicaid eligibility applications growing by leaps and bounds, the volumes of accounts per staff are a challenge providers have to tackle. Providers have to ask themselves whether they can handle the increases with the same staff (and skill sets) that were processing applications prior to reform, said Young.

To determine if they can in-source or will have to outsource, savvy providers mine their data, comparing the staff resources needed to address the volumes of Medicaid, self-pay and charity patients, for example, pre-reform and post-reform.

Harnessing the data around increased volumes is another top challenge for providers. Providers with successful Medicaid eligibility strategies know that they must get good control of their data because the data has important implications for provider revenues and processes. “Providers really have to sit down and look at that investment in technology that’s going to help them identify eligibility types...and also do that hard analysis by service line, diagnosis, by campus, by facility, etc.,” said Yoesle. “They must have that technology and they have to have that investment.”

With the technology to conduct deep dives into their data, these successful providers can continuously evaluate their processes around Medicaid eligibility. They can measure the components of processing Medicaid eligibility applications in order to continuously improve the process for themselves and their patients. They can compare pre-reform data to post-reform data for deep revenue cycle insights. And they can identify opportunities that will get patients engaged early and forgo administrative bottlenecks down the road.

Those organizations that make the leap—using their data and thinking strategically—are the ones that will thrive in the future, according to Yoesle. “Providers are doing do an admirable job of finding the right coverage for patients and helping them where they can,” he said. “It’s just an issue of bandwidth and then that issue of thought leadership—of taking it one more level to see where there are new opportunities to enhance the patient experience.”