Medicaid Claims Processing Challenges for Agencies

Similar to claims submitted to a private third-party payer, home care billers submit claims to Medicaid. However, there are many cases in which these claims differ. Since Medicaid is known for its high volume payer status, the claims must be sent directly to Medicaid.

That means the responsibility for these claims goes through the biller directly. It also means that billers do not need to go through a third party or clearinghouse to ensure that these claims are clear and accurate.

Medicaid Billing and Processing

Medicaid home care eligibility differs from state-to-state, which means claims for Medicaid are trickier than claims for Medicare or third-party insurers. When working with Medicaid patients, it is important to understand that Medicaid eligibility differs among states. As such, billing requirements and regulations also differ from state-to-state.

Creating the proper claim is up to the biller. Each state, however, has its own requirements for Medicaid claims. For example, one of the most important elements of a claim is the NPI, which stands for National Provider Identifier, like a social security number for healthcare providers. In general, the biller should use a standard claim form with all the relevant information such as the place of service, the health care provider’s NPI number, procedures performed, and the cost of the services provided.

Medicaid is different than Medicare. Medicaid tends to cover more services than Medicare does. Medicaid is the last payer to be billed for a service. If a patient’s insurance covers a service, first charge that insurance and then bill Medicaid only if the patient is uninsured or underinsured.

Operational Challenges in Medicaid

Medicaid-reimbursement is a challenging environment for private-duty agency owners because of its low margins and regular regulatory changes. With today’s high standards, the consequences of missing a visit hurt more than ever.

An agency owner may not have planned for this new environment, so being ready for it is crucial. In order to handle visit verification, operations need to be enhanced and in alignment. Relying on processes that are quick and automated takes the heavy lifting off of an organization’s shoulders that used to rely on manual data entry.

Solution:

Partner with a software company that has experience in both Medicare and Medicaid, but be sure that the vendor is not only on top of the latest regulatory changes but also proactively updating its software to stay ahead of these changes. When it comes to providing home care services for Medicaid beneficiaries, companies often see this as a good business expansion. However, it is important to understand the challenges that come along with such an endeavor.

Care Period and Staffing Challenges

There is a major difference between serving Medicare beneficiaries and Medicaid beneficiaries. While patients covered by Medicare may need care for several days or weeks, Medicaid patients can need long-term continuous care for months and years. Medicare reimburses customers for short-term post-acute care, but Medicaid recipients may need long-term care assistance.

Medicaid Home care service models are shifting toward the idea of forming long-lasting relationships with clients. This may be a hard shift for caregivers who are used to short-term delivery of care services, and for management worried about a difficult hiring environment marked by high turnover. The key to this is keeping an enduring pace even when some staff members leave.

Solution:

To maintain lasting relationships with their clients, home care businesses should focus on retaining staff and reducing turnover. The relationships created between clients and their care providers are likely to last much longer than those between patients and Medicaid beneficiaries.

To inform staff members of the crucial differences between Medicaid in-home care and Medicare home health care, let them know that Medicaid patients will “live” at home while Medicare patients are often sent to skilled nursing facilities.

To make billing, scheduling, and other routine operations easier to manage, and to stay ahead of payment challenges, train staff in advance on the changes that will occur with the new payment system.

Common Errors in Medicaid Billing

One of the biggest challenges that home care billers face today is the higher number of claim rejections due to manual or system errors. The key to lowering the number of rejections is to understand why they are happening.

• Incorrect Care Recipient Details: Gender, Name, Date of Birth, Insurance ID number, etc.
• Incorrect Care Provider Details: Address, Name, License, Contact details, etc.
• Errors in Codes: Punching in incorrect ICD, CPT, or HPCS codes; Place of Service codes; Unclear modifiers to HCPCS or CPT codes; and filling out claim forms with not enough or too many digits to an ICD, CPT, or HCPCS codes.
• Medical Codes Mismatch: Mentioningpuzzling ICD codes with CPT codes
• Duplicate Billing: Care providers sometimes submit a claim for a procedure without any knowledge as to whether or not the patient has already paid for the service. This can lead to duplicated billing and wastage of time in rectifying for both billers and payers.

Claims Management Done Right

· Single sign-on access to all payers is a time drain. Why should businesses have to log into one payer system and out of another? Instead, payers should be able to work from a single login.

· Mistakes are inevitable. Mistakes that are simple to make are more likely to be made. Your claim management software should directly resubmit the claim when mistakes are rectified.

· When you use a single integrated platform, it helps to prevent revenue slowdown and mistakes by eliminating the need to toggle between systems and screens.

· Real-time status checks are now the norm. It’s time for claims status, too. Today, it seems like everything is always open and available later on. When a service provider is able to check the status of claims in real-time, it helps to get paid faster.

Let the Experts Streamline Your Medicaid Claims Processing

We have the answer to your Medicaid needs. CareSmartz360 has been helping home care businesses with error-free billing and claims management.