Case Study

Improving Medicaid Eligibility Program to Boost Revenue

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Improving Medicaid Eligibility Program to Boost Revenue

An integrated approach to improving Medicaid eligibility program garners $20 million in one year 

An underperforming Medicaid eligibility program resulted in a loss of millions of dollars of revenue at three hospitals in a large health system. Parallon (formerly The Outsource Group), deployed an 11-person on-site staff to more effectively identify and case-manage Medicaid eligible patients, ultimately securing payment with these accounts. The result: an increase of $20 million in Medicaid payments in one year.

Client: National Health System

Facility Type: Large Acute Care Hospital | Pediatric Hospital | Small Community Hospital

CHALLENGE

An inability to adequately identify patients who were eligible for Medicaid or other programs was adding to days in accounts receivable and negatively impacting revenue.

HOW WE HELPED

Parallon initiated a three-month process that included discovery, recruitment, and training phases to improve revenue and increase patient satisfaction. In three short months we were able to:

  • Establish a comprehensive understanding of local qualifications and guidelines for Medicaid eligibility
  • Conduct a thorough review of online literature and met with local Medicaid officials to confirm application protocols and preferred methods of communication
  • Establish relationships with the local agencies that patient benefit advisors (PBAs) would be working with on a regular basis

The improved process included an end-to-end account lifecycle that incorporated a comprehensive operating platform consisting of initial screening and analysis, case management and development and quality assurance program and technology.

Recruitment and Training

To execute this platform, Parallon recruited a local team of 11 PBAs with Medicaid experience to work onsite at each of the hospitals. The PBAs underwent two weeks of training to learn proven practices in identifying possible eligibility, case managing applicants and customer service. The PBAs were also trained to educate patients to use clinics rather than emergency departments for non-urgent care to reduce their cost.

Going Live

As the new process went into effect, monitoring and feedback sessions were held for three months to gauge progress. Parallon team members continued working one-on-one with on-site staff for an additional eight weeks. The team also coordinated improved operational processes with personnel from each hospital in seven departments, including the business office, patient access, case management/utilization review, nursing, medical records, human resources and information systems.

RESULTS

Parallon’s process produced significant results in improving Medicaid eligibility for the hospitals. Certified paid Medicaid accounts increased by 53 percent, more than $20 million, year over year, while average patient screening days saw a reduction of 36 percent.

LESSONS LEARNED

  • Understand local rules and agencies for Medicaid eligibility
  • Establish communication channels with local Medicaid agencies
  • Provide one-on-one training for on-site staff
  • Proactively seek training feedback for sustained improvement

KEY BENEFITS

  • Increased revenue
  • Increased utilization
  • Reduced uncompensated care
  • Enhanced patient satisfaction
  • Improved process efficiencies