On the surface, the mission of a Medicaid eligibility (ME) team is simple: qualify patients for financial and medical relief, while increasing reimbursement to the provider. Of course, things are rarely as simple as they might initially seem, and that is certainly the case in the world of healthcare revenue cycle management.

It has been Parallon’s experience that the solutions to today’s ME challenges often are not the obvious ones. In a recent case, for example, a patient who didn’t qualify for a state Medicaid program had accumulated total charges of $362,222, and would have been responsible for at least $100,000 of that.

By connecting with the patient, establishing trust and asking the right questions, an eligibility advocate determined that the patient had recently become unemployed. Insurance coverage could be continued through the Consolidated Omnibus Budget Reconciliation Act (better known as COBRA), which gives workers and families who lose their health benefits the right to continue group health benefits for a limited time under certain circumstances, such as job loss, but the patient couldn’t afford the $1,300 premium payment.

Advocates refused to give up in their search for a solution. Ultimately, the hospital that was treating the patient paid the premium and was reimbursed $174,255. The patient’s potential cost saving from this mutually beneficial solution was $262,000.

The ongoing challenges that have in many ways intensified since early 2020 have hammered home the point that providers must tap into all the available ways of fulfilling their mission of serving their communities—now and in the future. Sustained financial well-being is vital to success.

Clearly a lot is at stake. And when it comes to reimbursement, the window for uncovering the appropriate payer is narrow. Success in this complicated area demands an in-depth knowledge of Medicaid and other payment opportunities, as well as the experience, tools and people to turn that knowledge into bottom-line results.

Recognizing Less Traditional Patients

The stereotypical picture of a Medicaid patient is typically someone below the federal poverty level, but in today’s healthcare economy that is a limited view. A Medicaid patient could be a woman who just lost her job and has a baby in intensive care, a person suddenly facing enormous medical bills for a recently diagnosed cancer, or someone in any number of other unforeseen situations.

Often patients who, for various reasons, find themselves without insurance coverage are ineligible for Medicaid because their income is above the maximum level for qualifying. During the pandemic, almost 8 million workers lost jobs with employer-sponsored health insurance, according to research from the Commonwealth Fund. Many of these workers and their dependents were not eligible for Medicaid.

Finding the Highest Profit Payer

More patients need access to care—and providers need to find the highest-profit payer. That means looking, when necessary, at options beyond Medicaid. Some patients have no other coverage sources, so hospitals must enroll them in Medicaid. Others qualify for Medicaid as well as coverage under COBRA.

Other coverage opportunities beyond traditional Medicaid include:

Staying up-to-date on these options and the changing rules and regulations surrounding them takes ongoing attention and effort. Knowledge of the disability arena, for example, reveals opportunities for patients who may be unaware that they qualify for disability; psychiatric patients, in particular, often get overlooked in eligibility discussions, resulting in a lost opportunity for both the patient and the facility. Other providers may not have considered options when it comes to COBRA coverage, a huge focus in a year when many people lost their employment, and the current presidential administration has reduced premiums (under the Affordable Care Act) to make them more affordable.

Your organization’s ability to stay on top of all available reimbursements and be fully compliant with state and federal (and even local) regulations in seeking these reimbursements, could make a significant difference on its bottom line. But you must first recognize the importance of thinking outside the box and, in some circumstances, looking beyond Medicaid.