Medicaid Payment and Reimbursement

Remaining nimble amid government regulation changes

June 17, 2019 6:10 pm

Medicaid is in a massive state of flux, and the challenge for healthcare finance leaders is to remain flexible and vigilant when change happens.

Medicaid regulations ultimately come from the federal government, and there has always been some flexibility to allow variation within each state program. But in recent years, the differences are becoming vast. Not only are the changes increasingly different with each state, it’s hard for healthcare organization leaders to wrap their heads around the details and impacts of these changes. In the world of Medicaid eligibility, especially for organizations serving multiple states, there are certain strategies that should be considered in this tumultuous time.

A big challenge for eligibility leaders is ensuring staff is abreast of changes to federal, state and industry regulations. As advocates for patients, we must have strong plans in place to remediate risks to their access to coverage.

When laws surrounding these government programs, such as Medicaid shift, they have a profound impact on the lives of patients and the ability to capture revenue retroactively, as well as moving forward.

The trends of change are vast. In some states, Medicaid may expand as a result of public referendum, along with state leaders over-riding the public vote. We are also seeing many states creating waivers, which adds to the complexity of the legislative decisions and leads to lawsuits from the public, adding yet another layer of uncertainty. Within the waiver, there are considerations of eliminating retroactive benefits, adding work requirements and requiring patients to pay premiums before they can obtain Medicaid. States continue to add to the list of new and experimental ideas.

How can we remain nimble despite a dynamic healthcare landscape? First and foremost, you have to understand each state separately and provide constant communication to staff and all stakeholders within an organization. Research, collaboration and having a secondary eligibility partnership are a few ways your organization can ensure strategic agility.

Detailed and constant research. Flexibility is not the only smart strategy. You must review the granular details on any major governmental change. You should have a clear understanding of how your organization will be impacted on a micro level and how regulation changes will create macro trends that healthcare as an industry will have to adapt.

Never assume a decision is permanent. Lawsuits within each state can stall or change the implementation dates. Pending waivers often look different from the approved waiver. Centers for Medicare & Medicaid Services (CMS) can make changes to waivers once they are approved.

There are many outlets available to stay up to date on legislative changes. Start by reading waivers and policies. You can find the latest data on the Kaiser Family Foundation or CMS’s websites.

Set up Google alerts and have trending news articles sent directly to your inbox. Also, follow healthcare reporters and relevant hashtags on social media.

Building relationships. Form and maintain one-to-one relationships with state officials, Medicaid offices and state hospital associations. That way, when changes arise, you have already established that relationship. That’s not to say you are acting as a lobbyist, rather, you have a point of contact to walk you through the complexity of changes on the horizon.

 When you locate these contacts, ask questions early and often. Each change will be new for everyone impacted and there will be many aspects of the changes that no one has considered. It is becoming increasingly important for state Medicaid divisions to partner with healthcare entities and other stakeholders. States aren’t always aware of the impact the changes have on healthcare entities.

Secondary eligibility vendor. Find a secondary eligibility vendor that has a dedicated focus on government relations. Spend more time focusing bandwidth on strategic and remediation planning while a vendor partner can spend more time doing research and following up on denials.

By being proactive and developing the capacity to change, your revenue cycle department can acquire the dynamism to respond as the Medicaid landscape shifts. 


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