What are the top features of optimal Medicaid payment technology?

Medicaid MCO claims management is complex and dynamic. The traditional approach to Medicaid payment policies and fee schedules is challenged by the increasing complexity of claims and dynamic state-by-state regulatory and payment environment.

Health plan leaders need to embrace technology solutions that enable accuracy while minimizing the lift for internal teams, especially with the variability in Medicaid. But what should you look for in your search for Medicaid Payment technology?

Top Features of Optimal Medicaid Payment Technology:

  1. Cloud-based service – Enables automated, frequent Medicaid and CMS regulatory updates to eliminate IT lift
  2. Depth of content – Includes reimbursement rates and payment policy for all care settings in each state, including facility and professional claims down to the provider level
  3. Claims payment process unification – Complete editing and pricing before adjudication
  4. Complete audit trail – Provides transparency that supports audits and improves provider relations

HealthEdge’s Source: Revolutionary Technology + Unique Depth of Content

With over 15 years of experience providing Medicaid and Duals support, our delivery of Medicaid pricing and fee schedules is unparalleled in the industry. As cloud-based platform, Source, is the only prospective payment integrity solution that natively brings together up-to-date regulatory data, claims pricing and editing, and real-time analytics tools into a single IT ecosystem. This transformational approach allows payers to make payments with total confidence and make business decisions with real intelligence.

The Value of a Great Vendor Partner

The ROI can be tremendous for health plans that find the right vendor partner. In one case a Source customer that processed 12+ million claims annually was able to reduce claim reworking by 40%, save approximately $6-12 per claim, and reduce IT overhead while gaining control of their workflow. The health plan improved CMS multi-state Medicaid program regulatory compliance, increased transparency on payment results, and spent less time preparing for audits, the latter of which increased staff satisfaction and retention.

Is a Traditional Approach to Medicaid Claims Payments Hurting your Health Plan?

Download our white paper Medicaid MCOs: It is time for a new claims management strategy to understand how our Payment Integrity solution, Source, is revolutionizing the way Medicaid claims are handled.

6 Ways Technology Can Lighten Your Medicaid MCO Team’s Workload

According to the Kaiser Family Foundation, there are over 280 Medicaid Managed Care Organizations (MCOs) that provide comprehensive managed care for over 55 million US adults, which is over 70% of all Medicaid enrollees. The diversity and economic status of the Medicaid population mean it can also be a more medically complex population than other payer sectors.

For health plan leaders that want to reduce these inefficiencies and drive down claims processing costs, they need to think differently and invest in solutions that lighten the load on internal teams while providing frequent and accurate data updates health plans need to succeed in managed care.

The typical release cycle for state Medicaid data varies from state to state, and updates can happen at any time. During natural disasters or events like the COVID pandemic, the number of updates to payment policies and fee schedules related to durable medical equipment and vaccine testing, for example, can increase dramatically. Unfortunately, since health plans typically only update Medicaid content at varying frequencies, improper payments are compounded during times of crisis, increasing the likelihood of rework.

In a typical large health plan, there may be 20-30 people managing the legacy process and increasing capacity means adding additional staff. Shifting from manually managing Medicaid MCO’s to cloud-based technology provides a myriad of benefits.

Six ways technology can lighten your team’s workload:

  1. Process claims correctly the first time. Avoid errors with up-to-date pricing and important edits in each state.
  2. Include all provider types and settings. Data that cover all providers in every care setting eliminate the need to piece together multiple data sources.
  3. Automate updates and data loads. Reduce the need to manually update data sets, which can result in delays and human error.
  4. Update more frequently. Quarterly updates can be too slow for an organization that wants to react quickly and remain agile.
  5. Keep an audit trail. Automate the audit trail so teams do not need to rely on incomplete archives that place the burden on the user to prove and support claims pricing results.
  6. Eliminate costly infrastructure. Moving to a cloud-based solution can reduce demands on internal IT and business teams as well as eliminate maintenance of costly legacy software.

By implementing a cloud-based claims processing solution that automatically updates the latest regulatory and pricing content, eliminates the need for infrastructure support, and maintains audit data, many of these talented individuals previously used to support the legacy system can be redeployed to more value-added responsibilities.

Download our white paper Medicaid MCOs: It is time for a new claims management strategy to understand how our Payment Integrity solution, Source, is revolutionizing the way Medicaid claims are handled.

7 Most Common Medicaid MCO Claims Management Risks

“Variability in Medicaid is the rule rather than the exception. States establish their own eligibility standards, benefit packages, provider payment policies, and administrative structures under broad federal guidelines, effectively creating 56 different Medicaid programs—one for each state, territory, and the District of Columbia.”

– Medicaid and CHIP Payment and Access Commission (MACPAC)

What does this mean for the 280 Medicaid Managed Care Organizations providing comprehensive care for over 55 million US adults? The complexity and variability in state-by-state regulations have health plan executives scrambling to keep up with each state’s latest Medicaid payment policies and fee schedules.

Within each state Medicaid program, there are numerous pricing models that may be based on patient population or geography. For the same procedure on a similar patient, a hospital in Stockton, California may have a different pricing model than a hospital in Sacramento. The diversity and economic status of the Medicaid population mean it can also be a more medically complex population than other payer sectors.

With the increasingly complex and dynamic state-by-state regulatory and payment environment, it has become nearly impossible to keep up to date with and adapt to the constant and nuanced changes in Medicaid payment policies and fee schedules.

But what are the real risks of not keeping up to date with the rapidly changing, dynamic world of Medicaid pricing? When fee schedules and configuring payment policies aren’t updated in real time?

  1. Health plan waste – Internal team is responsible for updating content, leading to high overhead, inaccuracies, and significant effort spent on IT infrastructure and maintenance
  2. Provider abrasion – Slow and inconsistent payments and repeated overpayment recovery strain payer-provider relationships
  3. Competitive disadvantage – Inaccuracies, lag, and strained provider relations can impair a health plan’s chances of contract renewals and winning bids.
  4. Overpayments – Using the wrong edits and price increases the risk of overpayments and downstream recovery
  5. Denials & Rework – Delayed fee schedule updates can lead to inaccurate claims. Payment policy and fee schedule as an incorrect fee schedule will likely not deny a claim.
  6. Missed Reimbursements & Incorrect Payments – Incorrect claims drive missed reimbursements & inaccurate payments
  7. Lost Time Resolving Payments Disputes – Payment disputes take up precious time

The traditional approach of Medicaid MCO Claims Management is inefficient and drives unnecessary costs for the health plan. For health plan leaders that want to reduce these inefficiencies and drive down claims processing costs and medical waste, they need to think differently and invest in solutions that lighten the load on internal teams while providing frequent and accurate data updates health plans need to succeed in managed care.

Download our white paper Medicaid MCOs: It is time for a new claims management strategy to understand how our Payment Integrity solution, Source, is revolutionizing the way Medicaid claims are handled.

Cloud-Based Technologies for a Competitive Advantage

Unlike a startup or smaller regional plan, many national health plans have grown their businesses by acquiring multiple smaller health plans along the way. While national plans gain new members through these acquisitions, they also often accumulate older and disparate technologies. As a result, national plans are often disjointed in terms of process and workflow.

Whether they are looking for operational improvement, administrative efficiency, medical savings, or any other initiative, it can be challenging to move quickly. Even with adequate resources and funding, national plans’ size creates more steps they must take internally and, in the industry, to transform their business. As a national plan continues to grow and increase the number of people, departments, and locations, these decision-making hurdles and issues escalate.

I often hear national plans ask, “how can we bring these different areas together to make things easier and improve operational efficiency?”

To modernize and innovate, national health plans need interoperable solutions that seamlessly integrate and connect their operations across the country. Cloud technology and cloud-enabled software can bring all these different areas together, even while physically separate from each other. With cloud-based solutions, everyone at a health plan is always working with centralized data and up-to-date information, reducing maintenance delays and potential errors.

This is extremely valuable for larger health plans. Once everyone at the health plan is working on the same tools, it makes collaboration easier and more streamlined.

The COVID-19 pandemic highlighted where outdated technologies present administrative deficiencies and the need for cloud-based solutions.

The pandemic created an entirely new regulatory environment that health insurers needed to accommodate immediately. Things were changing quickly. A large plan with disjointed systems did not just need to make changes in one place; they had to make them in several areas. The health plans that invested in cloud-based solutions had the flexibility to react quickly to the regulatory changes with minimal business interruption.

Cloud-based solutions can completely transform a national plan; however, it takes investment for progress. Health plans need to think differently about where they want to be in ten years, partner with next-generation technology creators, and invest in their future.