Managed Medicaid QUICK HINTS

1. PROBLEMS WITH MANAGED MEDICAID ARE DAUNTING
Failing to adapt to payer mix shifts jeopardizes revenue.
The good news is that none of these problems are new: Insurance verification, authorization, payment compliance, and poor claims processing have always been challenges.
The solution is simply to do everything you’ve always done...just better, more comprehensively, and more precisely.
2. MANAGED MEDICAID IS ITS OWN CLAIMS CLASS!
Simply following commercial claims edits or Medicaid edits is not enough. Many Medicaid HMO payers have implemented strict front-end edits – to match their edits your claim scrubber may need to be run in a specific sequence to ensure the right outcome is achieved on the final bill.
Passing out of your claim editor does not mean the claim was accepted into the TPAs system, which can lead to inappropriate timely filing denials.
Don’t accept “we never received that claim” from a call center representative. Use the trace number and pursue payment!
3. DEFINE INSURANCE VERIFICATION UNIVERSE
Coordinate with Manage Care Contracting to assemble a detailed list of Managed Medicaid Plans contracted with your health system; build a training package; maintain this list at least quarterly.
Review the Coordination of Benefits section on the eligibility check result (271 transaction) with all staff performing insurance verification.
Implement a “1st of the Month” process to re-verify all in-house patients with Managed Medicaid plans to catch cases with eligibility cut over between plans between months.
4. BUILD AN AUTHORIZATION MATRIX
This matrix will serve as a quick reference tool; the monthly process of updating this job aid doubles as staff training, and floor managers will know if staff are up to date on authorization requirements.
Address specific needs: e.g., implement a set process to handle newborn Medicaid cases. Each managed Care payer is likely to handle babies differently; a process will systematically ensure the newborn is covered either through traditional Medicaid or Managed Care Medicaid.
An automated Auth. Matrix tool helps, but even an excel spreadsheet on a shared drive reduces auth-related denials.
5. UNDERPAYMENTS AND DENIALS MANAGEMENT
Reimbursement rules are complicated and volatile: so an underpayment detection process, either through internal efforts or through a vendor, important. Review results and capture the themes so you can work with payers to systematically stop the underpayments and avoid excess vendor fees.
Managed Medicaid tends to have significantly higher rates of initial denials than commercial payers – track these denials closely. Build a denials management scorecard and a cross-functional team to implement process changes to prevent denials.
Dive deep on denials such as non-covered or lacks information, which often serve as a catch-alls for more specific claim info– including NDC codes, NDC units, or missing procedure codes.