When Erica was born, her parents knew something was wrong, but doctors could not determine a diagnosis. The family traveled to see specialists in three states at their own expense, and her parents felt alone and unsupported. Navigating the healthcare system is hard enough when you have just one or two physicians — it is even harder when your child is sick and has more than five specialists spread across three states.
Erica is just a fictional representation of a child with complex medical conditions, but her story is one that many families can relate to. Healthcare is a siloed industry, and nowhere is that more obvious than in pediatric specialty care. Children with complex medical conditions often receive care and treatment from multiple pediatric specialists in various care settings, hospitals and health systems. The lack of interoperability and data sharing and the challenges in coordinating care can lead to gaps in care, increased costs and poor outcomes. Compounding the challenges, children with complex medical conditions, such as Erica, must often seek care and treatment from specialists out of state.
To address these challenges, Congress passed the Advancing Care for Exceptional (ACE) Kids Act in April 2019. This forward-looking initiative is aimed at improving care coordination and outcomes for children facing complex health conditions and diagnoses.
The Basics: What to Know About the ACE Kids Act
Children with complex medical conditions are defined as children with at least one chronic condition —affecting three or more organ systems and reducing cognitive or physical functioning — who also require medication, medical equipment, therapy, surgery, or other treatments. Children with one life-limiting illness or rare pediatric disease are also eligible.
Most children with complex medical conditions are covered by Medicaid — they comprise just 6% of the pediatric Medicaid population but 40% of the spend in Medicaid, according to the Children’s Hospital Association. Unfortunately, research shows that only 19.2% of children ages 0–11 years old with complex medical needs receive care in a well-functioning system of care. For children ages 12–17, that percentage drops to 4.5%. The ACE Kids Act seeks to improve this percentage and address the nationwide lack of a comprehensive and integrated care system for children with medical complexities by leveraging Medicaid.
Starting on October 1, 2022, states had the option of offering health home services for children with medically complex conditions. A health home is a designated provider or a team of healthcare professionals — selected by the child and/or their family — who provides comprehensive care management; care coordination with out-of-state providers; help with accessing subspecialized care; referrals to community and social support services; and help with technology to link services. States that opt to create health homes receive a 15% increase in federal matching for their expenses on health home services during the first six months. The bill also allows a total of $5 million for state planning grants.
The Impact of the ACE Kids Act on Out-of-State Medicaid Claims
More than 85% of children’s hospitals serve out-of-state patients, according to a report from the Medicaid and CHIP Payment and Access Commission (MACPAC). Generally, hospitals that treat out-of-state patients receive payment from an average of three states. However, children’s hospitals typically receive Medicaid payment from more than six states — in fact, some children’s hospitals receive Medicaid payments from more than 25 states.
Although it is critically important for children to receive the care and treatment they need from specialists and professionals, the behind-the-scenes work can be burdensome and challenging for revenue cycle teams. Attempting to collect on out-of-state Medicaid claims can be difficult. As a revenue cycle leader, you face challenges that include:
- Varying Medicaid policies. States have varying Medicaid policies and regulations. Understanding and navigating just one state’s policies can be difficult — doing so for multiple states is even more challenging.
- Timely reimbursement. Medicaid reimbursement processes can be slow, and delays in reimbursement can cause financial strain for children’s hospitals that are already operating with razor-thin margins.
- Documentation requirements. Every state has specific documentation requirements for Medicaid claims. Making sure that documentation is completed accurately can be time-consuming — and mistakes can result in denials.
- Appeals and denials. Speaking of denials, these can be more complicated for
- out-of-state Medicaid claims.
- Resource constraints. Staffing shortages continue to plague children’s hospitals, and many revenue cycle teams do not have the bandwidth to manage the complexities of out-of-state Medicaid claims.
How EnableComp Can Help
EnableComp has more than 20 years of experience handling complex claims — including out-of-state Medicaid claims. We stay up to date on the ever-changing policies and regulations associated with Medicaid so that you’re not leaving potential revenue on the table. With an average 3:1 ROI, our clients often see an increase of more than 50% in out-of-state Medicaid payments once they partner with us.
Outsourcing with EnableComp helps you:
- Simplify out-of-state Medicaid enrollment
- Maximize operational efficiency
- Reduce out-of-state Medicaid authorization denials
- Improve the financial health and well-being of your organization
To learn more about out-of-state Medicaid claims and how EnableComp can help, download our white paper “Navigating Out-of-State Medicaid & Getting Paid for Claims: The Essential Guide for Chief Revenue Cycle Officers.” [Navigating Out-of-State Medicaid and getting Paid for Claims]
