Why Is Out-of-State Medicaid More Complicated Than In-State?

Medicaid billing isn’t overly difficult when it occurs in-state, but take it out of state, and it gets incredibly complicated. Each state’s Medicaid plan operates by its own rules, deadlines, and policies. To get paid, you must know all the specific nuances of each state Medicaid plan you bill and how to nurture a claim all the way through to its full payment. Doing so requires expertise and resources. 

One of the main differences in out-of-state vs. in-state Medicaid is that out-of-state pays for claims only if they involve:

• A medical emergency
• Endangering a patient’s health if they travel back to their home state for care
• Services or resources that are more readily available out of state for the patient
• A general practice that patients in your location use medical resources in another state 

What Are Some of the Most Pressing Out-of-State Medicaid Challenges?

Healthcare organizations that pursue out-of-state Medicaid reimbursement on their own are up against some steep challenges, especially because each state is different and out-of-state Medicaid rules are changing all the time. Here are some of the reasons out-of-state Medicaid billing is more complex than in-state billing. With out-of-state Medicaid claim submission:

• Regulatory changes occur constantly, impacting all phases of out-of-state Medicaid billing. 
• Submitting a clean claim requires regular interaction with each state Medicaid agency and timely knowledge of each program’s rules, regulations, processes, and policies.
• Providers — including hospitals, health systems, and ordering, prescribing, and referring physicians — must be enrolled in a state’s Medicaid plan to bill there. 
• Most states require detailed confidential disclosure information for enrollment, such as Social Security numbers and addresses of board members, copies of provider driver’s licenses, etc., which is often difficult to acquire easily from providers because of privacy concerns.
• Provider numbers need to be updated and maintained with the states to reduce provider-related claim denials.
• The patient’s Medicaid eligibility needs to be confirmed prior to billing, and patients with dual eligibility (i.e., also eligible for Medicare) may complicate billing.
• Prior authorization is often required for medical service, and prior authorization requirements may vary; denials or delays may occur. 
• Billing codes and Medicaid reimbursement rates may differ between states, meaning understanding the differences and accurately coding claims are essential.
• Medicaid agencies put claims through a variety of data checks before payment is made. 
• If all the requirements for payment aren’t made in a timely fashion, denials can occur.

Navigating the Out-of-State Medicaid Claims Filing Process

Getting an out-of-state Medicaid claim paid takes a team of experts and the latest in revenue cycle management artificial intelligence. It requires coding, billing, and legal expertise. And above all, it requires thorough knowledge of Medicaid billing processes in all 50 states.

Chasing down out-of-state Medicaid payments is no easy matter. Without experts to help, many claims don’t make it through. That’s why most providers end up having to write off these services — and that’s an unwanted hit to your bottom line.

Successful out-of-state Medicaid billing requires:

• Enrolling your facility and physicians in the out-of-state Medicaid programs and HMO plans required for billing
• Making sure that all enrollment documents are completed in full, sent to you for review and signature
• Using the correct billing codes and following the billing procedures and guidelines specific to each state
• Ensuring provider numbers are updated and maintained with the states to reduce provider-related claim denials
• Confirming patient Medicaid eligibility and gaining prior authorization (when needed)
• Using technology to check claim edits to ensure compliance and quality control
• Seeking assistance from consultants or experts in Medicaid billing, especially when dealing with complex billing cases

Because there are so many hoops to jump through, it is difficult to capture all your out-of-state Medicaid claims. Revenue cycle team members at most organizations are already stretched, and maintaining current knowledge of state Medicaid claims is difficult, at best. Enrollment alone is a minefield for billing because, without it, out-of-state claims reach a brick wall. Healthcare organizations that bring in experts to meet these complex billing needs will have the advantage.

At EnableComp, we believe you deserve to get paid for the work you do. Our experts have years of experience billing Medicaid in all 50 states and know how to deal with out-of-state Medicaid challenges. We know enrollment inside and out, and how to keep your providers up to date. We have contacts we can call at Medicaid plans when a situation reaches an impasse, and our regulatory experts keep abreast of Medicaid policy changes before they unfold. We augment claims processing with new technologies and data sources. We leverage best-in-class AI and automation for efficiency while our expert team provides the insight, understanding, and adaptability that only humans can offer. That’s why clients that team with us often see an increase of over 50% in out-of-state Medicaid payments.