Case Study

Beyond Medicaid: Going the Extra Mile to Investigate on the Provider’s Behalf

Beyond Medicaid: Going the Extra Mile to Investigate on the Provider’s Behalf

The art of conversation is a key skill in the Medicaid eligibility (ME) advocate’s tool kit, along with diligence, persistence and the willingness to ask just one more question. It breaks down barriers created by a combination of unfortunate circumstances, fear, uncertainty and perhaps skepticism. Patients confronting unforeseen health issues usually have accompanying financial concerns and may be hesitant to share personal information with a stranger, even if that information is necessary to solve the reimbursement puzzle and get them the assistance they need.

Patients must be assured that the ME advocate is on their side, working to relieve them of financial worries while getting them the care they need. The ability to build trust and ask the right questions is empowered by training and empathy, with the help of data analytics, as the advocate gathers the pieces and puts them together in an effort to improve the patient experience while also meeting the provider’s cash flow needs.

But sometimes the situation still calls for a little more.

Going the Extra Mile

The following real-life story, which could be called “the case of the missing patient,” reinforced something we already knew at Parallon: Sometimes you have to go the extra mile to close the case.

A patient with a $500,000 medical bill was not responding to outreach attempts by an eligibility advocate. One harsh reality of dealing with uninsured or underinsured patients is that once a patient has left a hospital or other healthcare facility, the chances of linking him or her to an insurance program drops significantly. In this case, the patient was gone and could not be contacted, and the provider was nearing the end of its fiscal year with that costly account still on its accounts receivable. The case was outside the normal scope of this team, but the situation required that we look beyond the normal scope.

A thorough investigation revealed that the patient was in jail—and a patient who is incarcerated or in custody is ineligible for Medicaid. But members of the ME team got permission to visit the jail and interview the patient, and the review produced the information needed to get the patient a charity application, along with supporting documentation. That account, adjusted before the end of the fiscal year, made a half-million-dollar difference in the provider’s bottom line.

It’s no mystery that Medicaid eligibility is all about taking care of both the patient and the provider—ensuring that the patient has the financial relief needed to focus on his or her well-being, and that the provider has the cash flow needed to serve its community.

Successful ME representatives know their patient population and how to communicate with patients as well as case management. They also know the value of asking one more question or conducting one final bit of investigation. And, if it’s necessary, they’ll even go to jail to solve the case.