Out-of-State Medicaid


Our team has been providing out-of-state Medicaid enrollment, billing, and collection services for over twenty years. We’re experienced with all state Medicaid plans.

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? We operate as an extension of your business office and bring our detailed knowledge of the regulations and requirements of 50 different Medicaid programs. We handle this work for over 140 hospitals, and that means we’ve already experienced the difficulties and challenges your employees have been facing when attempting to obtain reimbursement for these claims.

We can also address your Medicaid prior authorization needs. We submit the necessary payer forms, follow up to confirm proper processing, and manage all requirements and submission destinations. This reduces authorization denials and leads to faster payments

What are the Greatest Challenges Related to Out-of-state Medicaid Claims?

Here are the biggest challenges faced by hospitals when it comes to pursuing out-of-state Medicaid claims on their own.

Regulatory Changes

Consider the effort required to stay up-to-date with Medicare regulatory changes. Now multiply that by 50. Then add the numerous Medicaid managed care plans States update Medicaid program rules, regulations, processes, and policies regularly. Unless you’re enrolling providers with and billing claims to a state regularly, it’s nearly impossible to maintain the knowledge required to submit clean claims and get them paid. We work with all 50 states and has developed processes and relationships to remain up to date as the programs evolve.

Provider Enrollment

State Medicaid programs require that hospitals, health systems, and providers be enrolled in the program before claims may be submitted and paid. Under the Affordable Care Act, even physician providers listed on claims (Ordering, Prescribing or Referring) must be enrolled for screening purposes before the facility claim can be paid. The physician enrollment can be a non-reimbursement / non-billing enrollment. Without a well-designed system to manage initial enrollment, maintenance of provider numbers, and associated credentialing, this can be a daunting task.

The enrollment process can be very cumbersome. While some states are making strides to ease the enrollment burden for out-of-state providers, they remain the exceptions. Most states require detailed confidential disclosure information for enrollment, such as Social Security numbers and addresses of board members, copies of provider drivers’ licenses, etc. Internal hospital resources may balk at even asking for these items. We have developed communication techniques that help the individuals involved understand why the enrollment process is critical. In many cases, board members and physicians are more comfortable providing this information to a trusted third party.

Our Process

Provider Applications and Enrollment

We enroll your facility and physicians in state Medicaid programs and HMO plans as required for billing. All enrollment documents are completed in full by our staff and sent to you for review and signature, making this process effortless for you. Provider numbers are updated and maintained with the states, thereby reducing provider-related claim denials.

Eligibility Verification

We confirm patient eligibility and determine timely notification requirements.

Prior Authorization

Our staff informs our clients of any payer authorization requirements for the service being billed.

Billing and Follow-up

Our sophisticated system edits ensure compliance and quality control. Claims are submitted within timely filing requirements to the proper payers.

Account Reconciliation

We provide specialized month-end reports for your easy reconciliation, including claim inventory, payments, and invoice summaries.

Appeals

We submit claim and payment appeals when applicable and represents your hospital in subsequent hearings where allowed.