Managing Managed Medicaid

Challenges

Billing Complexities

The biggest catch with managed Medicaid is the diversity of the billing and claims processes. Many providers are used to the traditional, fee-for-service Medicaid, which is a generally straightforward and reliable billing process. Now with managed Medicaid, facilities must navigate networks of managed care organizations (MCOs) to manage authorizations, submit claims and follow up to get payments. These new processes can be time-consuming and confusing and are compounded by the fact that many of the MCOs newly managing Medicaid benefits are struggling to maintain accurate authorization data and process claims. Cash flow cycles are impacted.

Delayed Payments and Denials

Making it through the maze doesn’t guarantee timely payments or approvals for nursing home claims - MCOs handling Medicaid benefits increase the risk of denials and delays for multiple reasons. Specific problems we’ve seen include MCOs failing to provide and maintain accurate records of authorizations, failures to make edits in their billing and payment systems so even correct claims are getting rejected; some are ill-prepared to handle the volume of claims and get completely overwhelmed. The financial impact of switching to Managed Medicaid can be significant for facilities with significant Medicaid populations.

But as I’ve said before, it is here, and we’d best be prepared for action to keep cash flowing.

Tips to Manage your Managed Care Medicaid Billing

Here are five tips to help manage your Managed Medicaid billing more efficiently:

1. Look at your process for obtaining and managing authorizations for care. Typically State programs are easier to work with and authorize longer spans. MCOs will authorize shorter periods and will be very strict about not paying without an auth. Every payer will be a little different, so be sure you know the landscape well.

2. Make sure you set up your MCO payers correctly in your software. This includes rates, codes needed for clean claims, and accurate accounting of your aging balances. Using a generic payer on your GL, such as “Managed Medicaid,” if you are dealing with multiple MCOs, may not let you track performance and collections from one MCO to another. 

3. Consider revising billing cycles from weekly to biweekly or monthly to minimize the resources needed for claim revisions. With reliable State Medicaid payers, billing weekly can stabilize cash flow. Now with MCOs, billing weekly can quickly become a compounding issue. If claims need to be corrected for 2 months, that can be 8 new claims or PDRs per resident. If your operation can sustain once or twice monthly billing, it will likely simplify life for your business office. 

4. Check eligibility very regularly. Residents can switch plans from one month to the next. It’s not very common, but it definitely happens, so be alert

5. Make sure your interdisciplinary teams know about the rules for MCOs and the opportunities that can be created through clinical approaches. Strong clinical relationships can build census and create more revenues for your organization.