What is Retroactive Medicaid Eligibility and how can we utilize this RCM billing strategy?

It is estimated that up to 5% of all accounts written-off as uncompensated care by hospitals are actually for services rendered to patients whom are eligible for Medicaid coverage. Self-pay patients continue to receive services at healthcare facilities as Medicaid-pending patients while they await their eventual Medicaid credentials.

When a hospital fails to identify new Medicaid registrants within their self-pay population, the hospital is often unaware of their ability to bill Medicaid for fees for services. Just because you may have originally missed identifying a patient’s eligibility doesn’t mean you’ve missed the opportunity to be reimbursed by Medicaid. Medicaid coverage may be effective retroactively, identified retroactively, and billed retroactively.

Hospital Revenue Cycle Solutions (HRCS) has the tools and expertise to find these billable accounts and bring that revenue back to your hospital.

How it Works

HRCS’ Data Analytics team reviews live bulk Medicaid data and scrubs your self-pay accounts against new Medicaid registrants via advanced big data analytics and software mapping from your hospital’s systems. We find those Medicaid patients that you’re missing so that your billing staff or ours can file a claim within timely filing limits and collect these patients’ fees for services.

Benefits of Retroactive Medicaid

  • Improved cash flow – We help you turn your potential write-offs into cash-producing claims.
  • Pay only when you get money — We are so confident in our ability to increase your revenue that we will work on a contingency basis.
  • Quick results — We can produce results for your organization in 30 days.

Real Results

Hospital Revenue Cycle Solutions was selected to partner with a large, metropolitan hospital with more than 400 beds and a net patient revenue of $178 million. The hospital had implemented a leading electronic health record tool for their professional services to help improve denials. However, through analysis by our team, it was determined that the tool did not always supply sufficient information to accurately verify coverage. To compound the issue, we also discovered that the process to re-verify eligibility the day before was not consistently followed.  And, even when it was determined that the coverage was invalid, the patient record was not always updated to reflect “self-pay”.

Our healthcare revenue team resolved the issues and was able to collect $796,130 in retroactive Medicaid for the hospital within 15 months. In addition, denials due to eligibility were reduced by 89%.

See more healthcare revenue cycle case studies here.

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