When your mission is to maximize reimbursement, it pays to be persistent and refuse to take no for an answer on submitted claims. Successful Medicaid eligibility (ME) representatives also learn that they sometimes need to go beyond their usual area of concentration to serve both the patient and the provider.

Recently, a patient’s application for retirement benefits was denied on a technical basis, presenting a challenge for Parallon’s ME team. As it turned out, incorrect Social Security processing had led to the denial of Medicare benefits when the patient applied before turning 65 years old. The team advocated on the patient’s behalf and got the Social Security Administration (SSA) to review the case. The review determined that the patient was indeed eligible for retirement benefits—but that’s not all! Through the spouse, the patient also qualified for Medicare benefits. The SSA reversed its initial decision and made Medicare Part A coverage effective retroactively to June 2020, when the patient turned 65.

Although Parallon’s ME team typically doesn’t handle Medicare, in this case we were able to provide that service to the hospital, which received a payment of $257,768. Because Medicaid would have paid only $97,000, the end result was a revenue net increase of more than $160,000 for the provider. Meanwhile, the patient got financial relief in addition to the necessary healthcare.

Multiple Opportunities for Financial Relief

In spite of its name, the ME landscape is not always just about Medicaid. Eligibility in any form means looking at multiple opportunities to qualify a patient for financial relief. Depending on the state and sometimes the county, various programs are available. Several managed care entities could be operating within a given Medicaid program, for example. Share-of-cost opportunities, which involve a monthly amount (like an insurance deductible) paid for healthcare before Medicaid kicks in, may also be available to different degrees.

Beyond traditional Medicaid, there’s also Medicaid disability along with other programs, including Medicare on the federal level. Many patients have disabling conditions but don’t realize it. Because disability is bigger than simply the physical conditions that people can see, a successful eligibility advocate can find opportunities to qualify patients who aren’t visibly disabled yet have disabling qualifiers. Certain psychiatric conditions and medical histories can make a patient eligible for such a qualifier.

While we tend to think only of “standard” Medicaid, a government program for patients who are living below the poverty level, there is much more to it than that—and ME representatives should be aware of these opportunities and adept at figuring out when they are viable options.

COBRA, the Affordable Care Act, charity programs and more are also potential reimbursement sources to be pursued, when appropriate, by ME representatives who know the needs of the patients they serve and continuously look for the opportunity to qualify them for the right financial relief. Armed with knowledge, analytical tools, determination and a passion for helping providers and patients, these representatives provide the customer service that allows healthcare providers to do what they do best: care for the patient.