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Best Practices for Patient Eligibility & Advocacy

Best Practices for Patient Eligibility & Advocacy

Effective Processes: Doing the Right Thing, the Right Way, at the Right Time

What happens in your healthcare organization when benefits—Medicaid, Medicare, Social Security or other—are denied for a patient? Do you have processes in place to advocate on that patient’s behalf or uncover alternative solutions that will serve the patient as well as the provider?

This common scenario is just one example of the many challenges facing today’s providers in the Medicaid eligibility (ME) landscape. Providers must pursue every possible reimbursement source if they are to ensure their own financial well-being. Effective processes are a result of having the right people in the job, armed with the right knowledge, tools and support to do their jobs the right way and at the right time.

Every process related to ME should be aimed at producing greater benefit for the patient and higher revenue for the provider. The right processes span a wide range of functions: hiring, training and education, support, compliance, quality assurance, streamlined workflows and much more. They also allow the flexibility to think creatively about effective, albeit nontraditional, ways to serve the patient and maximize reimbursement for the facility.

Every Step of the Journey

Here are just a few examples of the ways that effective processes work for the good of patient and provider through every step of the healthcare journey:

  • Data analytics: Data analytics drives propensity-to-pay scores and spots trends, enabling better conversations with clients and a more targeted approach to pursuing sources of reimbursement. Gender, demographics, geography, diagnosis and other factors are weighed in the determination of whether an account is high or low probability for Medicaid or other assistance. This scoring allows ME representatives to take a more targeted approach to screening patients, taking into consideration the differences among individual states’ Medicaid programs.

  • Prescreening: A prioritized screening process pinpoints opportunities for identifying unexpected reimbursement programs, creating coverage for the patient and reimbursement for the provider. Additionally, prescreening eliminates unnecessary touches for patients, freeing up resources for those who are more likely to qualify for programs and therefore bring higher reimbursement.

  • Scripting: Scripting guides the patient-advocate communication process; at the same time, empathy and the building of trust ensure that patients are directed to the best reimbursement source while being connected with on a human level.

  • Follow-up: ME representatives hold patients’ hands throughout the healthcare journey, educating them and helping them understand next steps. After an application has been filed, follow-up with patients and agencies ensures that all the necessary documentation has been gathered, the application has been assigned to an eligibility worker and every possible step has been taken to obtain or continue coverage.

  • Streamlined workflows: Providers and their partners work together at implementation to define the optimum workflow to ensure the timely capture of patient populations, enable bedside screenings, facilitate the uploading and signing of documents and effectively follow up with patients.

  • Compliance and quality assurance: A focus on compliance with all rules and quality assurance is woven into the fabric of operations, throughout every stage. Given the ever-changing regulatory environment, scripting and application submission processes are updated frequently. The ongoing education of everyone involved in the process is critical. Quality assurance reviews conversations and applications to ensure compliance at the federal, state and local levels.

  • Flexible processes: While structured processes are essential to the streamlining and increased efficiency of ME functions, they are flexible enough to allow for timely adaptation when changes occur. Ongoing research, communication and education ensure that everyone is up-to-date on changes.

Baked Into the Day-to-Day

Deep knowledge, experience and a willingness to approach challenges in a new way enhance the overall patient journey. Doing the right thing the right way—and at the right time—comes naturally when it is operationalized: baked into the day-to-day processes that drive the organization.

Clear, thorough and ongoing communication throughout the organization and with all involved parties keeps everyone on the same page and working together toward the common goal: greater benefit for the patient and higher revenue for the facility.