Medicaid Eligibility: The High Price of Free Healthcare

The four saddest words in today’s healthcare industry: “Put it in writing.”

Healthcare has become a sea of paper and supporting documentation (or e-records). In spite of efforts to the contrary, ink bleeds into every corner of the industry, both on the clinical and revenue cycle side. It will come as no surprise to anyone in healthcare that the difference between getting paid or writing off an account to bad debt can be as little as a signature on a single form or providing appropriate documentation.

When it comes to government healthcare programs--especially the subject of this article, Medicaid--bureaucracy has and continues to drive the financial engine. While some healthcare providers became adept on the “mechanics” of the process, patients were overwhelmed.

From its inception in 1965, Medicaid has required that patients and/or their families fill out an application and provide financial and medical information, depending upon what aegis of the program they fell under. If the boxes were not checked, the fields not filled out, the signature not made, documentation not provided, outstanding treatment dollars for Medicaid patients slid into bad debt and patients did not receive the ongoing coverage for care they desperately needed.

Over time, providers lost significant Medicaid reimbursements because of misunderstanding changing regulations, missing patient information, lack of patient engagement and consent. A cottage industry of patient advocacy firms grew up to better connect the dots between provider, patient and the government.

Now, along comes the Patient Protection and Affordable Care Act, which included the opportunity for the states to expand Medicaid along with offering healthcare insurance coverage. Thirty-two states

and the District of Columbia agreed to some version of expansion, and take up the federal government on its offer. One of the purported benefits, in addition to greater federal reimbursement (at least initially) was that the application process would go online, and, in theory at least, become more streamlined.

The process of moving Medicaid applications online has mirrored the health insurance exchanges/marketplaces. Some states have elected to create their own portals, some operate portals jointly with the federal government, and others have opted to have the feds run the portal altogether. We are now two years into Medicaid expansion and our clients in those states that accepted it are seeing some measurable improvement in the level and quality of care for certain low income populations.

While moving the application process online has been an improvement, the need for patient advocacy has not disappeared. Many Medicaid-qualified patients still fail to properly fill out forms or continue to submit incomplete or inaccurate financial and medical information. Many times the data accessed electronically is inaccurate or simply doesn’t exist.

While the application process has been streamlined, the challenges faced by patients who potentially qualify for Medicaid have not entirely changed, among them:

Lack of access or understanding of the technology. Despite the omnipresence of the internet, several Medicaid eligibles don’t have access to it or, what is probably more common, an aversion to using it due to confusion about the process.

Cultural bias. There are those who may be qualified Medicaid patients whom are immigrants and potentially considered (depending upon the program and status) “qualified aliens.” However, they may originate from countries where they have learned from an early age not to trust the government, a belief to have matters handled within their own family or community as well as language barriers.

Higher priorities elsewhere. Several Medicaid eligibles have to make difficult choices about utilizing their limited resources and time. Do I go to work or complete a financial assistance application? Do I spend money for food or on a taxi to get a birth certificate? Do I pay a medical bill or keep the lights on for another month?

Medical conditions limiting patients ability to comply with the application process. Many times qualified Medicaid eligibles have a medical condition (physical or behavioral) which hinders their ability to complete the process to obtain coverage. This in essence, can be the difference between getting healthy and dealing with a much more serious health dilemma that can be fatal. If there are no family members or guardians who can be the voice of these patients, they continue to be at risk.

As healthcare providers have learned, the need for patient intervention is not going away with expanded Medicaid. If anything, it has become more nuanced and in some cases more difficult due to the misconception of ease. At the same time the stakes have grown much higher since reimbursements from other revenue sources are shrinking dramatically. In the next article, we’ll look at ways that providers can fine-tune their patient championing efforts to get the most from their limited resources.

The Challenge for Healthcare ProvidersThe challenge for healthcare providers is not Medicaid eligibility; the challenge is making sure those that are eligible for Medicaid get enrolled correctly.

200 14th Ave East | Sartell, MN 56377 | 888-340-7243 | www.arraysg.com

I outlined some of the obstacles healthcare providers face enrolling Medicaid eligibles. Despite the advances that resulted from the Patient Protection and Affordable Care Act, specifically by moving the application process online, many qualified Medicaid patients continue to slip between the cracks and from there slide into bad debt.

For healthcare providers, the ACA is mostly good news with relation to Medicaid, at least in the 29 states and District of Columbia that consented to some version of expanding the program. By increasing the income range under which patients qualify a greater number of low income individuals can get the level of care they require and better clinical outcomes.

Healthcare providers are still required to work with patients to assist with the financial assistance process. Even though more people qualify for Medicaid, they still are required to complete applications and have some level of income verification and, depending upon the program, supporting evidence of qualifying medical conditions.

While providers understood that the number of Medicaid eligible patients under the ACA would increase, there also was a perception by many that the new streamlined application process would absorb the need for any additional resources to manage the growing volume.

This resulted in many providers taking the following steps:

• Some reduced staff and resources to those departments or individuals responsible for patient application intervention with the expectation that the new streamlined process will result in fewer Medicaid eligibles getting away.

• Others relied on Navigators or in-person assisters provided by the state or federal government to be available to patients who have questions or don’t understand the process.

• Still others maintained or even increased budgets for patient advocacy efforts, but found that despite the increased resources the number of Medicaid eligibles slipping into bad debt has increased.

At least in our experience, many healthcare providers are coming to the realization they underestimated potential website, data, and application limitations and the sheer volume of potentially qualified applicants. They found that the new online application process, though more efficient, has not eliminated the need for patient intervention to help complete applications, obtain supporting documentation, and correct application errors.

There is still a need to track the states’ progress on making timely and correct decisions due to increased volume. Many have observed that this has not been an entirely smooth transition and unfortunately there is still a need to file fair hearings and appeals.

If you have maintained your patient advocacy function and yet you still are seeing large or growing numbers of Medicaid-qualified individuals failing to enroll (especially those with high medical expenses), then you should consider increasing resources to that function or outsourcing some or all of the patient advocacy functions.

The challenge for healthcare providers is not Medicaid Eligibility; the challenge is making sure those that are eligible for Medicaid get

enrolled correctly.

Copyright © 2015, all rights reserved NEW 203A

Author: Sherry DobbsManager,

Medicaid Eligibility Operations

200 14th Ave East | Sartell, MN 56377 | 888-340-7243 | www.arraysg.com