Bill resolution. Patient peace of mind. Provider reimbursement.

These goals are top priorities for any Medicaid eligibility department. Their achievement is key to ensuring that the system functions the way it should: with patients receiving attentive care, and providers receiving the cash flow they need to fulfill their mission at a high level.

A successful eligibility department is well-equipped from both a human and a technological perspective. First of all, it is staffed with empathetic people trained to have intelligent, heartfelt conversations with patients. And those people need effective tools to help them identify potential candidates for coverage programs. A marriage of process and technology ensures that, during treatment (or after, in some cases), patients are thoroughly screened to determine the right matches between candidates and programs.

Eligibility is an ongoing challenge for providers as they seek to maximize reimbursement in a time of financial uncertainty. The best shot at bill resolution for treatment of an uninsured patient is to reach that patient early in the process—at the time of service, if possible—and determine the best approach for obtaining coverage.

Technology plays a major contributing role at various stages of the process, from securing and sharing documentation to completing applications for coverage and keeping in touch with patients along the way. In addition to elevating the patient experience, it harnesses data analytics to ensure that eligibility advocates are reaching the right patients. Through the use of finely tuned algorithms, patients are identified and matched with the right coverage. The patient qualifies for financial relief, while the provider gets the best possible return.

Working Smarter

The right technologies, such as Parallon’s Interactive Patient Benefits Advisor (iPBA), can:

• Enable patient ease of access. Health events can be stressful, so the less a patient has to worry about treatment and payment, the better.
   
• Allow patients to self-screen or be screened remotely to see whether they meet criteria for coverage.
   
• Enhance patients’ ability to provide eligibility advocates with the information they need to find the right solution.
   
• Empower communication on behalf of patients who are unable to complete applications or provide necessary paperwork on their own.
   
• Facilitate the remote and expedited uploading, exchange and signing of essential documents.
   
• Connect the patient with the right coverage program, whether that be Medicaid, spousal coverage, COBRA (Consolidated Omnibus Budget Reconciliation Act), the health insurance exchange, charity or another resource.

In one recent case, a patient had accumulated charges totaling nearly $285,000 during a 30-day hospital stay. The case had been pending at Disability Determination Services, but the patient was unable to sign the required paperwork.

Parallon eligibility advocates used iPBA to get the paperwork from the patient’s family, and the patient ultimately was approved for Supplemental Security Income-Medicaid. The resulting coverage became effective from the time of admittance, providing relief from charges that, as of this writing, had reached $346,922.

Powerful Tools in the Right People’s Hands

Technology can’t do it alone, of course. Resolution of the above case, for example, also required aggressive work, assertiveness and successful request by eligibility advocates for a presumptive decision by the state agency.

Technology is a pathway to a desired goal, but it alone doesn’t get you there. It can focus and streamline communications, whether internal, client-facing or patient-facing, but if you don’t have the right people in the picture, technology is only technology. In the hands of the right people, however, it can be a game changer.