The Provider Enrollment Headache: Overcome Challenges Associated with Out-of-State Medicaid Hospital Claims

Posted October 13, 2022 by Hamilton Bowman

Out-of-State Medicaid reimbursement poses significant challenges to healthcare facilities. Many choose to write-off these difficult claims. Those who attempt to work these claims internally typically experience success rates so low, they likely don’t seem worth the effort. It’s a daunting task for an internal billing team to keep track of all the rules and requirements governing Medicaid, as they are continually changing and vary from state to state.

One of the biggest challenges healthcare facilities face when dealing with Out-of-State Medicaid is managing the provider application and enrollment process. Before a claim can be submitted to Medicaid, the facility and the providers must be enrolled in the specific state’s program being billed. Without a well-designed system to manage initial enrollment, maintenance of provider numbers, and associated credentialing, billing departments will struggle to process these claims correctly.

The provider application process requires a high level of protection and compliance with each state’s legislation. Most healthcare facilities don’t have the internal expertise to manage this process, nor do they have the bandwidth to ensure updates are being made on a regular basis in accordance with the latest amendments within each state, much less meeting their unique timely filing deadline.

In fact, many healthcare organizations consider this the most painful step in the Out-of-State Medicaid reimbursement process. Missing the opportunity for reimbursement due to all of these complex factors proves to be costly.

The Affordable Care Act (ACA) and the Centers for Medicare and Medicaid Services (CMS) implemented a requirement that all ordering, prescribing, and referring providers (OPR) who treat Medicaid patients must complete OPR provider enrollment. This was put in place for additional integrity requirements that are placed on state Medicaid programs. The basic OPR provider enrollment requirements include:

  • The provider who wrote the order/prescription/referral must be enrolled in Medicaid (either as a participating Medicaid Provider or as an OPR provider).
  • The provider’s NPI must be included on the claim.
  • The provider’s NPI must be for an individual or non-physician practitioner (not an organizational NPI).
  • The provider must be of a specialty type that is eligible to order, prescribe, or refer.

While provider enrollment has been the biggest challenge hospitals, health systems and providers have experienced, there are several additional challenges associated with billing Out-of-State Medicaid claims. These challenges demand time, expertise, and resources internal billing teams may not have. Focusing on the below additional requirements, without a third-party extension to your revenue cycle team, most likely translates to a drain on resources and an insufficient volume of revenue.

  • Eligibility Verification:
    • First and foremost, before any action is taken to bill an Out-of-State Medicaid claim, verifying a patient’s eligibility to receive care must be completed. Taking on this task internally means allocating dedicated billing staff to ensure coverage and determine timely notification requirements.
  • Prior Authorization:
    • The process for obtaining prior authorization for Out-of-State Medicaid claims is cumbersome. If the necessary payer forms are missing, if there is no follow-up to confirm proper processing, and/or there is a lack of management for all requirements and submission destinations, authorization denials increase, and payments will eventually stop.
  • Billing and Follow-up:
    • The billing process for Medicaid also differs by state. All states require a UB for facility charges, and HCFA for professional charges, but some states do require accompanying forms or have additional requirements such as a list of covered services and reimbursement rates. Internal billing staff will need to devote time to follow-up on delayed or denied claims, sometimes unaware of why the claim was initially rejected.
  • Maintaining Qualifications and Revalidation:
    • For each state Medicaid program, a facility must maintain its qualifications according to the program’s requirements, and their specific providers must complete periodic revalidation with the program(s). Failure to do so will result in deactivation with the Medicaid program and denied claims. If a provider is un-enrolled, re-enrollment will entail more time and work and there may be a gap in eligibility for reimbursement.

What can providers do to minimize these challenges and increase the bottom line? With today’s hyper-focus on increasing revenue while lowering costs, it is imperative for healthcare facilities to appropriately allocate staff on areas that generate the highest yield. This is especially important for departments that have a direct association with managing reimbursement. Revenue cycle departments are quickly realizing that focusing on non-complex claims is the jackpot for increased reimbursements.

However, writing-off complex claims could mean leaving a significant amount of cash on the table. This is where EnableComp can help! Our team has been providing Out-of-State Medicaid enrollment, billing, and collection services for over twenty years and understand the process to successfully capture reimbursement for all state Medicaid plans. With more than 140 hospital clients across the nation, we operate as an extension of the business office and bring our detailed knowledge of the regulations and requirements of 50 different Medicaid programs.

Our clients often see an increase of over 50% in Out-of-State Medicaid payments once we take on the work. How do we accomplish this? Contact us and we’ll be happy to provide you a free data assessment to show how we can increase your Out-of-State Medicaid payments.