A health insurance claim form along with the blog title – Out-of-State Medicaid Reimbursement: Top Challenges & Solutions

Out-of-State Medicaid Reimbursement: Top Challenges & Solutions

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EligibilityAdvocates Blog

Out-of-State Medicaid Reimbursement:

Top Challenges & Solutions

Posted on Friday, February 5, 2021

Out-of-state Medicaid reimbursement poses significant challenges to healthcare facilities. Many choose to write off these difficult claims. Those that attempt to work them experience success rates so low, they don’t seem worth the effort.

Fortunately, you don’t have to lose out on this valuable revenue.

Below are the top challenges to out-of-state Medicaid reimbursement along with the ways in which EligibilityAdvocates can help you solve them.

Challenge: Changing Regulations


A health insurance claim form along with the blog title – Out-of-State Medicaid Reimbursement: Top Challenges & Solutions

EligibilityAdvocates has expertise in each Medicaid program and can help solve your challenges to out-of-state Medicaid reimbursement.

It is very hard for an internal billing team to keep track of all the rules governing Medicaid because they are continually modified and vary from state to state. Each state, U.S. territory, and Washington, D.C. has a separate Medicaid program with its own requirements and processes. If you do manage to find an employee with this niche expertise, an additional challenge arises in retaining the employee or retraining someone else if you face turnover.

Solution: EligibilityAdvocates provides a team of experts who specialize in out-of-state Medicaid and every unique Medicaid program while staying up-to-date on all new laws and policies.

Challenge: Enrollment of Facility AND Providers


Before you can submit a claim to Medicaid, you must enroll your facility and providers in the specific state’s program you are billing. This is a very involved task as it typically requires gathering sensitive personal information (e.g. social security numbers, home addresses, copies of driver’s licenses, signatures) from each of the hospital’s board members and/or physicians. Even ordering, prescribing, and referring (OPR) providers for Medicaid patients must complete OPR provider enrollment.

Enrollment must be completed in a timely manner so that you don’t miss your window for reimbursement. The enrollment process and which documentation each program requires for enrollment differs by state, further adding to the difficulties. In fact, may healthcare organizations consider this the most painful step on the road to out-of-state Medicaid reimbursement.

Solution: EligibilityAdvocates completes, submits, and maintains your facility AND provider enrollment applications at no additional cost to you. Save yourself the money, time, and headache it takes to accomplish this job and simply let us do it for you.

Challenge: Billing & Follow-Up


The billing process for Medicaid also differs by state. Each program has its own claim forms, billing requirements, list of covered services, and reimbursement rates. Even a simple error like using the Medicaid billing template for your own state to submit a claim to another state’s program can result in a denied claim.

Your billing team will need to devote time to follow up on delayed or denied claims, sometimes unaware of why the claim was initially rejected.

Solution: The EligibilityAdvocates out-of-state Medicaid team has experience in all 50 states’ billing procedures. We will bill and follow up on each out-of-state Medicaid claim for you, ensuring no claim is neglected, as well as take care of the appeals process for any denied claims when necessary. Not only are our team members specialists in claims resolution for Medicaid and out-of-state Medicaid, but our Medicaid expertise and pre-arrival workflow solution also prevent errors and issues that cause denials, underpayments, and reimbursement delays in the first place – providing you with higher remittance and quicker reimbursement.

Challenge: Maintaining Qualifications & Revalidation


For each Medicaid program you wish to bill, your facility must maintain its qualifications according to the program’s requirements and your providers must complete periodic revalidation with the program(s). Failure to do so will result in deactivation with the Medicaid program and denied claims. If a provider is un-enrolled, re-enrollment will entail more time and work and there may be a gap in eligibility for reimbursement.

Solution: EligibilityAdvocates provides maintenance and monitoring of all your Medicaid credentials to prevent expirations and deactivation and to make sure you are proactively maintaining compliance with each program.

Challenge: Drain on Resources


Each of these challenges requires time, expertise, and resources that your staff may not have or that they cannot afford to take away from their other billing responsibilities. Focusing their attention on out-of-state Medicaid reimbursement is not the best use of their time and your money if they do not collect a sufficient volume of revenue.

Solution: EligibilityAdvocates is a performance-based extension of your revenue cycle team. Our services are strictly contingent, meaning we don’t get paid until we’ve delivered on our promise to get you paid. The revenue we bring in will always exceed the cost of our services and your employees can focus on other objectives while we manage your complicated out-of-state Medicaid work.

Solve Your Out-of-State Medicaid Reimbursement Challenges with EligibilityAdvocates


Outsource out-of-state Medicaid work to EligibilityAdvocates and we will take on these challenges for you. No longer will you need to assign time, energy, stress, and staff to these complex claims or write them off as bad debt.

We will handle all aspects of out-of-state Medicaid enrollment, billing, and follow-up for you, so you don’t miss out on this substantial source of revenue. Contact us today and start collecting the out-of-state Medicaid reimbursement you are due!


By Stephanie Salmich

Three people look at financial reports and the blog title appears: New Year’s RCM Resolutions

New Year’s RCM Resolutions

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EligibilityAdvocates Blog

New Year’s RCM Resolutions

Posted on Friday, January 15, 2021

While many people are eager to start a new year and put 2020 behind them, COVID-19 continues to impact healthcare facilities in numerous ways – including financially.

A recent survey of hospital executives and finance leaders found that since the pandemic started, there has been an increase in bad debt, uncompensated care, self-pay patients, and Medicaid patients for over 40 percent of participants.

In response to these challenges, we’ve listed practical actions you can take this year to protect your revenue and reduce uncompensated care.

Here are five New Year’s RCM resolutions:

Resolution #1: Financially Clear Patients Prior to Their Date of Service


Preventing errors on the front end of the revenue cycle is an ideal way to avoid payment delays, denials, underpayments, and extended A/R that contribute to bad debt.

EligibilityAdvocatespre-arrival workflow solution streamlines financial clearance activities such as order/referral management, (real-time) insurance verification, preauthorization, and (real-time) medical necessity verification. Automating steps performed by Patient Access limits deficiencies and integrity issues that have a negative impact on the revenue cycle.

Resolution #2: Ensure Your Organization Is Payer of Last Resort


Three people look at financial reports and the blog title appears: New Year’s RCM Resolutions

Set these New Year’s RCM resolutions to help you achieve your revenue cycle goals.

To reduce bad debt, it is imperative that all possible funding sources are exhausted for a patient account before it is designated as uncompensated care. There are numerous options available, including:

  • Medicaid
  • Out-of-State Medicaid
  • Presumptive Eligibility
  • Crime Victim Compensation
  • Disability – SSI/SSDI
  • Qualified Health Plan Enrollment
  • State & County Programs
  • COBRA
  • Veterans Benefits
  • Indian Health Services

EligibilityAdvocates screens patients for their eligibility in all the above using our proprietary software, AdvocatorAI.

The screening process can begin immediately, as our patient advocates are equipped with tablets and can meet with the patient at bedside or in the field and deliver instant results.

Additionally, our pre-arrival workflow solution searches for unreported health coverage and our patient advocates help patients enroll in health plans so that they are covered for future visits at your facility.

An added benefit of our technology solutions is that they facilitate a “touchless” process with patients. We can conduct the screening process with AdvocatorAI over the phone and complete financial clearance prior to patient arrival, which helps limit the number of people at your facility during the COVID-19 pandemic.

Resolution #3: Stop Writing Off Out-of-State Medicaid Claims


Out-of-state Medicaid billing is complex, but hospitals that write off these claims miss out on a substantial form of reimbursement.

If you are unable to devote the necessary time and resources to working these complicated accounts, outsource out-of-state Medicaid claims to a team of experts who can do the work for you.

EligibilityAdvocates handles all aspects of out-of-state Medicaid enrollment (for both facility and providers), billing, and follow-up. We have experience in all 50 states’ programs and our early determination and single point allocation allow for more Medicaid conversions, higher remittance, and faster reimbursement.

Resolution #4: Improve Patient Engagement & Patient Responsibility Collections


EligibilityAdvocates provides one-on-one patient financial counseling and education to help patients navigate their healthcare finances. And our in-person meetings between patients and patient advocates result in higher conversion rates, increased point-of-service payments, and the establishment of patient payment plans.

The more your patients understand the financial aspects of healthcare (such as health insurance, financial assistance opportunities, and how to decipher their medical bills), the more likely they are to pay their patient responsibility. Patient financial stress is often related to confusion over what is owed and why, which leads to delayed or non-payments.

Resolution #5: Outsource Patient Eligibility & Enrollment


You will experience a greater return on investment if you pursue these objectives with the help of an outsourced and on-site patient eligibility and enrollment service.

Managing these tasks internally requires the expenses of an in-house staff (e.g. pay, benefits, hiring, initial and ongoing training, office space, phones, computers, printers, desks). These are costs that must be paid whether employees recover an adequate percentage of revenue or not.

On the other hand, if you outsource patient eligibility to EligibilityAdvocates, we offer performance-based pricing; you only pay us a percentage of the money we collect and none of the labor costs. We also provide OP/ED staffing at up to 24 hours a day and 7 days a week, which contributes to our higher success rates.

Keep Your New Year’s RCM Resolutions with EligibilityAdvocates


When you partner with EligibilityAdvocates, we will make sure you reach each of these goals and more.

Contact us today and get started on your New Year’s RCM resolutions right away!


By Stephanie Salmich