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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 on a quarterly basis, improper payments are compounded during times of crisis, increasing the likelihood of rework.


“ Variability in Medicaid is the rule rather than the exception” – MACPAC


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.

About the Author

Jared has been working in the payer reimbursement and payment integrity sphere for around two decades. As chief strategy officer at HealthEdge Source, Jared continues to work closely with health plans to understand their unique challenges and deliver solutions that can achieve their long-term goals.

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