It’s a given that dealing with Medicaid is going to be challenging. Trying to get claims paid can be demanding, frustrating, time-consuming, and just overall maddening. And that’s when you’re dealing with your own state’s Medicaid program! When you have to work with out-of-state Medicaid programs, the additional complexity escalates all of it.
Here are the five biggest challenges to getting your out-of-state Medicaid claims paid:
No, you don’t see a typo, and no, there isn’t some wacky computer glitch causing the first three challenges in our list to be the same.
The top three challenges to getting your out-of-state-Medicaid claims paid are indeed enrollment, enrollment, enrollment, says Dee Dee Germroth, Argos Health’s senior vice president of Medicaid Solutions.
“Enrollment is just major,” she says. That’s because every single state has its own enrollment requirements. “(Enrollment) is the hospital’s biggest headache.”
Provider partners such as Argos Health understand hospitals’ pain. Germroth has been specializing in state Medicaid programs for more than 25 years and has seen (and experienced) all the hoops hospitals face when enrolling.
“The enrollment process is absurd. The amount of detail that some states ask for is mind-boggling. It’s a headache, and it’s so time-consuming for their staff to do,” she says. “And then, they get through all the enrollment hoops, and guess what? The application comes back rejected because the authorized signer didn’t sign in blue ink.”
Here’s a fairly common enrollment scenario: A Medicaid enrollee from another state – let’s say New Jersey – is traveling through your state and is in an automobile accident and ends up in your emergency department for treatment.
To get paid, your facility has to be enrolled with the Medicaid program in New Jersey. Now, if you’re located in New York, your facility probably is already enrolled with the Medicaid program in New Jersey, given geographical proximity and the frequent back and forth between the two states’ residents.
But, if your facility is not already enrolled, you will have to go through that process and be approved before submitting a claim for payment.
The enrollment process varies from state to state and what each state requires differs, too. “It’s not a simple process,” Germroth says.
One of the most significant sticking points in enrollment is the requirement for personal information from every person sitting on the hospital’s board. That means personal information such as their Social Security numbers and home addresses – things that many board members do not feel comfortable sharing, and it may take some convincing to get them to provide such information.
Hospitals also have to have individual providers – doctors, hospitalists, etc. – enrolled. The hospital itself can be enrolled and approved, but a claim could be denied if the attending physician is not enrolled. This is a requirement that rolled out with the Affordable Care Act.
And note: The enrollment of individual physicians isn’t so that the physicians can get paid, she says. It’s so that the hospital can get paid. And getting those documents, which include information such as the physician’s license number, Social Security number, specialties, home address, and signature, can be a lengthy task that takes up a lot of staff time.
Some states also require documentation that the hospital has enough liability insurance. Others want the hospital to provide certificates of good standing that confirm the hospital is in good standing with its community and state. “Those are not always easy documents for everybody to get their hands on,” she says.
“We do enrollment for every single state and managed care organizations all day long, so it’s not that big of a deal for us as long as we have the necessary information they want,” she says.
Once the hospital has gone through the enrollment process, which may have taken many weeks, it can finally bill. But if your billing department uses your state’s Medicaid billing template, you may find the claim denied, Germroth says. As with enrollment, state Medicaid billing requirements vary. “Now the hospital has sent out a bill that didn’t get paid, so the hospital staff has to follow up by calling to find out why the claim was denied,” she says. “The staff chases the bills because they do not know what other states require to get claims paid.”
An out-of-state Medicaid claim often runs into trouble from the very beginning, Germroth says. When the hospital’s registration staffer gets the patient’s insurance information, it may not be evident that the insurance is Medicaid or which Medicaid product they’re enrolled with. The patient may say, for example, “I have Medicaid of Texas,” but really, it’s Blue Cross Blue Shield of Texas, which is a different payer altogether, as your billing office will learn when Medicaid of Texas denies the claim. Your billing staff then has to spend time tracking down who the correct payer is and then resubmitting the claim to that payer. Because these things can take such a long time, you run the risk of getting that resubmitted claim to the correct payer after their claim submission window has closed. Then you don’t get paid but have put all those staff resources and effort into it. “From the very beginning, identifying and knowing who is your actual payer is critical,” Germroth says.
When hospitals understand how much uncompensated care from these claims is impacting the bottom line and recognize how much of a drain on their staff time processing these claims is, they can choose to become proactive by outsourcing those claims to an experienced partner like Argos Health. Learn more about our Medicaid Services and how we can be your partner by going here or filling out our contact form here.