Medicaid Payment and Reimbursement

8 KPIs for measuring Medicaid eligibility and advocacy

July 7, 2019 12:55 pm

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

How are you currently measuring your eligibility and enrollment success? Clearly defining KPIs for your leadership to track progress or to report where challenges are cropping up are instrumental in building a successful eligibility program.

When you’re ready to take a hard look at your eligibility performance, or if you merely need help deciphering the Medicaid eligibility reports that hit your inbox, these recommendations may be helpful.

Comparable data

Before evaluating data, make sure you are 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 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 may not expect a vendor to count that as a conversion. However, some vendors will consider it a conversion, which is why it’s important to set clear expectations, so everyone is on the same page when discussing KPIs.

KPI checklist

While nomenclatures may vary, here are example metrics you should be generating internally or receiving from a vendor on a monthly basis:

  1. Application numbers. How many patients have applications for Medicaid or other programs completed?
  2. Conversion rates. How many applications were approved versus the number of patients that were screened?
  3. Denial breakdowns. What are the patterns behind denials? What are some of the underlying issues?
  4. Days from referral to application submission. How swiftly is the team working to enroll patients?
  5. Days from application submission to approval. How successfully and rapidly are those applications being approved?
  6. Screening percentages. What percentage of accounts have been screened?
  7. Volume of placements. How many patients have been enrolled? How many reimbursable accounts?
  8. Gross placement dollars. What is the total amount of dollars being collected from enrollment in Medicaid, Supplemental Security Income or other programs?

Uncovering room for opportunity

Data alone is insufficient. Analyzing KPIs reveals information about trends and enables you to paint a narrative of the “why” behind what’s happening.

If you are not routinely evaluating your Medicaid eligibility and advocacy performance, and your organization is seeing high self-pay accounts receivable balances, that should be a huge warning sign that operations need to be refined. Analyzing metrics may lead to ask the following questions:

  • Have there been staffing changes?
  • Is staff productivity not keeping pace?
  • Why are screening rates down?
  • What is the turnaround time for applications, and why are there delays?
  • What are the reasons for denials?
  • Are there any environmental changes that are impacting your organization?

If you set up a reoccurring KPI review process, 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?

Industry benchmarks don’t necessarily exist. So much will vary based on your state and the type of patient population you serve. 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. 


googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text1' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text2' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text3' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text4' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text5' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text6' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text7' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-leaderboard' ); } );