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Platforms for Excellence in Medicaid Eligibility Operations

Platforms for Excellence in Medicaid Eligibility Operations

The infrastructure of any successful Medicaid eligibility operation includes, at its core, comprehensive data generation, robust reporting and targeted sharing, along with machine learning. These tools empower the operation to fulfill its dual mission of providing greater benefit to the patient and higher revenue to the hospital.

The right platforms and technologies enhance the overall process and ME representatives’ ability to do their job and positively shape the patient experience. They also help the client get to the right patients—the ones with the highest likelihood for reimbursement, ensuring the biggest return for the facility.

Indispensable tools include those that can:

  • Recognize the various Medicaid programs nationwide and their many differences.
  • Assist with application management so patients can be linked up with programs that generate revenue for the facility.
  • Look for eligibility across multiple states and find coverage for a patient who becomes sick or injured during an out-of-state visit.
  • Run data science algorithms behind the scenes to drill down into inventory and diagnosis (aged, blind, disabled, pregnant, with children in the home, etc.) and determine the probability that a patient will link to a program.

Automation Enables Intelligent Conversations

The intelligent conversations that are so essential to pinpointing and meeting a patient’s needs are enabled by analytics and technology that produce accurate and timely documentation. ME representatives can more quickly peel back the layers of a patient’s medical and financial history by generating a report detailing, for example, today’s patients who visited the facility six months ago and had insurance that paid.

With this information at their fingertips, representatives can have better focused conversations with patients, asking them the right questions and directing them toward the right reimbursement source, such as coverage that was overlooked during registration, or a lapsed policy that can be restored by paying the premium.

There are other ways automation and data science allow an ME department to be more effective in providing its services and positioning itself for the future. Automated file processing, for example, can bring together multiple accounts that may be in one person’s name, determine patients’ likelihood of paying their balance, pinpoint those who need to be contacted and recommend a course of action.

Properly configured telephone dialing technology can be used to target the patients whom ME representatives didn’t get to talk to in the hospital. It also can streamline the payment process for patients, allowing them to pay without talking to a representative if that is their preference.

From a compliance standpoint, the right platforms automate workflows, scripting and other communications to ensure regulations are followed during conversations between the representative and the patient. They also optimize communications, whether internal, client-facing or patient-facing.

Remote Tools Get the Job Done From a Distance

Having the right technology infrastructure in place allows for a quick pivot when sudden change happens.

As many patient representatives and other healthcare support personnel shifted to work-from-home settings during the pandemic, technology enabled numerous functions to be conducted remotely. Those included patient screenings; completion of insurance applications; quality assurance monitoring; and the uploading, exchange and electronic signing of documents.

Tools are also available that allow patients to screen themselves remotely. Successful ME operations use these screening tools to facilitate the gathering, sorting and analysis of patient-generated information, as well as the detection of trends and patterns.

The Right Technology, Used Properly, Pays Off

For many healthcare facilities, Medicaid eligibility has historically been a largely manual process involving much high-touch work with the patient to uncover potentially minor reimbursement. While technology can streamline processes and facilitate reimbursement, smaller vendors are unlikely to own these platforms, and many larger companies may use them only superficially.

Used properly, however, the right tools and technologies can identify patterns of denials and other trends so that the chance of future denials is sharply reduced, patient access is expanded and provider reimbursement is increased. And, at a time when every dollar counts, that money can add up significantly.