Revenue Cycle

Are you ready for the Medicaid ‘unwinding?’

Six steps hospitals can take to prepare.

May 2, 2023 10:00 am

The phase-out, or “unwinding,” of the three-year Medicaid continuous enrollment program began on April 1, and states have started to disenroll ineligible members. They have 12 months to complete the recertification process.

The HHS estimates that around 8.2 million Medicaid enrollees, of which 4.7 million are adults ages 18 to 34, will lose Medicaid coverage, while 5.3 million children will lose CHIP coverage. These individuals could find it incredibly challenging, especially those that live in one of the 12 non-expansion states. The HHS suggests that hundreds of thousands will have incomes that are too high to qualify for Medicaid but too low to qualify for Marketplace tax credits.

Impact on patients

First and foremost, the unwinding is likely to confuse enrollees who may find it difficult to understand the details of their change in coverage. Each state will have its own method and timing for the recertification process. According to an article published by Catholic Health World, few are going out of their way to make it a smooth transition for enrollees. With many state agencies still experiencing staffing shortages, enrollees are likely to experience long hold times when calling into overwhelmed state agencies for help.

The situation could be dire for those losing their coverage completely. Many of these individuals will lose access to a primary care provider, leading them to put off care and stop taking their medications. For those with chronic conditions like diabetes or heart disease, the result could be life-threatening.

Impact on providers

The recertification could cause chaos for American hospitals as they face an increase in the number of uninsured patients using the emergency room because they see no other options. Unless hospitals increase their attempts to find financial assistance for these individuals, they will likely experience an increase in write-offs and charity care.

The impact goes beyond those patients who are losing coverage though. Those whose coverage has been altered may find it difficult to navigate the changes. This means they will likely depend on the hospital to educate them on their new coverage. But hospitals, especially those with limited staff, may be hard-pressed to find the patient’s new coverage and eligibility information in the first place. Already overburdened staff will have to spend more time researching and checking multiple sources to ensure they’ve got the most current, accurate information for each patient.

The bottom line for providers is that the unwinding of Medicaid will make it exceedingly difficult to predict and protect revenue, especially for hospitals whose payer contracts are based on volume. This volume will now be difficult to estimate. At the same time, providers are also likely to see denials soar as it becomes more difficult to determine eligibility. As if that weren’t enough, they should also prepare for patient payments to become even more challenging to collect, especially self-pay payments.

Where to turn

There are many steps hospitals and health systems can take to mitigate the impact of Medicaid unwinding. The following are six opportunities that can be implemented quickly and can deliver a reasonably quick ROI.

  1. Implement automated technology. One of the most effective steps hospitals can take to prepare for the impending chaos is to amp up their use of automation technology.  According to an article in Becker’s Hospital Review, “antiquated state eligibility systems and processes will profoundly impact providers.” Automated solutions use the latest technologies like artificial intelligence (AI) and robotic process automation (RPA) to identify and capture accurate coverage and eligibility information as well as current demographic data. This can help hospitals collect better social determinants of health (SDOH) data, which will become increasingly important in their post-pandemic population health efforts.
  2. Offer flexible payment plans. Now is also the time for hospitals to implement flexible patient payment plans if they haven’t already. These plans should be based on a patient’s unique financial circumstance and set up with affordable monthly payments. These plans should be flexible enough to add additional family members; it’s much easier to pay one monthly medical bill rather than two or three. In this way, patients are able to afford the care they need when they need it. And this can enhance the patient experience and raise hospital customer satisfaction ratings as well.
  3. Use propensity-to-pay analytics. Another good option is to use propensity-to-pay analytics to determine if a patient is able to pay. It’s a waste of time sending multiple statements only to eventually turn the account over to an agency and collect pennies on the dollar. Understanding a patient’s ability to pay enables providers to proactively determine qualification for financial assistance or charity care. In these cases, hospitals should take the time to help patients fill out and submit their applications, rather than just provide the information. In this way, hospitals become an advocate for the patient in a way that helps build loyalty and word-of-mouth referrals.
  4. Offer multiple payment options. Yet another step hospitals can take is to make it easier for patients to make their payments. Besides friendly payment plans, hospitals should consider convenient options like payment portals or digital payments. These should be offered in concert with traditional options like printed statements, electronic statements and phone payments.
  5. Provide patient responsibility estimations. In one survey, 40% of patients who had tried getting information about their out-of-pocket costs before receiving a service could not do so, or the information they found was inaccurate. Providing estimates prior to or at the time of service allows patients to make more informed decisions about how to pay for their care. It also provides a great opportunity to ask for payment upfront.
  6. Consider outsourcing. In reality, many hospitals don’t have the time or resources to implement new technologies or processes. In these cases, outsourcing is a great option. Look for a partner that invests in the latest automated technology and analytics solutions. The right partners can deliver enhanced value and improved efficiencies that go straight to the bottom line — all without the heavy lifting on the part of the hospital.

The time to act is now

Although states have 12 months to complete the recertification process, hospitals shouldn’t wait. Taking proactive steps now can help protect their bottom lines and ensure long-term financial viability.


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