What KPIs Should I Measure for Medicaid Eligibility?

What KPIs Should I Measure for Medicaid Eligibility?

Focus on moving the needle by growing revenue and driving down high self-pay A/R balances

We’ve all heard the saying, “You can’t manage what you can’t measure.” When evaluating Medicaid eligibility performance, there are many considerations for assessing internal eligibility staff or eligibility vendors using key performance indicators (KPIs).

When you’re ready to take a hard look at your revenue cycle performance, or if you merely need help deciphering the Medicaid eligibility reports that hit your inbox, the following recommendations can aid your efforts:

The Main Metric

Medicaid eligibility can be evaluated in several ways, but the measurement that matters the most to CFOs is self-pay accounts receivable (A/R) balance. High self-pay A/R balances are a huge warning sign. If those balances continue to rise, the success of your enrollment efforts in eligibility and other reimbursement programs will come into question.

Comparable Data

Before evaluating data, make sure you’re comparing apples to apples. When you’re reviewing monthly operating reports, you need to know the story behind the numbers you see so you can pay attention to the right metrics. Knowing how certain activities are counted isn’t just to measure ratios (like conversions), but also to determine whether you should be paying a vendor for a conversion.

For example, if you have an account registered as self-pay but is later covered by commercial insurance, you wouldn’t expect a vendor to count that as a conversion. Nor would you expect them to charge for that. However, some vendors will consider it a conversion, which is why it’s important when discussing conversion rates to all be on the same page.  

Standard Reporting

Here are two reports you should be generating internally or receiving from a vendor:

Placement Analysis Report. This report should answer questions such as:

  • Based on what you received from a client in a certain month, what was your success with those accounts?
  • How many patients were seen?
  • Of the patients seen, how many had applications?
  • How many of those applications were approved for Medicaid?

Activity History Report. This report might be a different slice of the same information as the placement analysis, but broader in scope. It also includes more information about how a vendor keeps up with the volume of patients.

  • What volume of self-pay admissions did you see in a month?
  • What is the breakdown of service type: Emergent versus non-emergent?
  • How many patients did you screen?

The most common measurements to analyze your vendor’s performance are:

  • How many referrals were handed to you?
  • How many applications did you take?
  • How many did you get approved?
  • How many did you get denied?

Reports like these reveal information about trends and enable you to drill down into why something may be happening:

  • Are there staffing changes?
  • What are the reasons productivity isn’t keeping pace?
  • What are the reasons for denials?

Another KPI Worth Your Attention

In addition to large or growing self-pay A/R balances, one other critical metric should set off alarms: declining screening rates on your placement analysis report. If you are seeing a decline in applications, then you will see fewer converted dollars.

If caught early, you can identify problems that need attention and expect a plan for remediation. If your current vendor isn’t providing these plans or you don’t have the resources to do it yourself, you should seek a vendor who can deliver the people, process and platform to drive success.

What Does Success Look Like?

There aren’t necessarily industry benchmarks. So much will vary based on your state and the type of patient population you are serving. Vendors that have experience with organizations similar to yours in terms of size or scale and serve your state will be in a better position to set expectations for what you can expect to accomplish.

To request a complimentary retro review of your inpatient and outpatient self-pay accounts, contact Parallon’s Medicaid eligibility team.