How Medicaid Monitoring Captures Retroactive Coverage & Reduces Unpaid Claims

People frequently gain and lose Medicaid coverage. A patient who is eligible one day may lose or scale back coverage the next. They may transition between traditional Medicaid and managed care plans or gain partial coverage that later shifts to full coverage. It’s a heavy lift to keep track, but it’s necessary for providers to reduce uncompensated care levels and bad debt write-offs.

Medicaid coverage is often found through insurance discovery. Even if the patient has already identified a primary source of coverage, it's worth double-checking. Through insurance discovery, providers can capture retroactive coverage, ensuring they receive appropriate reimbursements for services rendered.

Understanding Medicaid & Insurance Coverage Changes

Medicaid is a government-sponsored source of healthcare coverage designed for people of all ages and demographics with limited resources and income. People frequently gain and lose Medicaid coverage depending on their life circumstances, employment status, or shakeups in the healthcare system like Medicaid unwinding (AKA Medicaid redetermination).

Patients undergoing these life changes may not remember to submit their new coverage to a provider. They may not even be aware they qualify for Medicaid as a source of coverage and instead expect to be classified as self-pay. In these cases, it’s up to the provider to determine the status of their Medicaid coverage.

What is Retroactive Medicaid Eligibility?

Retroactive Medicaid eligibility allows individuals to be covered for medical services provided up to three months before their application approval. This is a good thing, as providers can collect payment for services provided even when the patient is uninsured. 

However, identifying retroactive Medicaid coverage is difficult without effective Medicaid monitoring tools, like insurance discovery. In lieu of automated checks, financial staff often work directly with the patient and payer in a time-consuming process.

How Insurance Changes Impact Claims Processing

To properly process a claim, billing systems must align with a patient’s current coverage status. As stated, Medicaid patients often come with nuances. Providers risk sending the wrong information to the payer without real-time monitoring, resulting in claim denials or lost reimbursements. Consistent Medicaid monitoring is one of the best ways to boost the provider’s first-pass claim rate for increased revenue recovery.

The Financial Impact of Missed Coverage on Healthcare Providers 

According to the American Hospital Association, “since the start of 2022, the number of days cash on hand for hospitals and health systems has declined by 28.3%.” Providers are already fighting for their bottom line; missing eligible coverage only exacerbates the issue.

Missed retroactive coverage is an example of a “silent revenue leak,” or a small instance of lost revenue that adds up over time. When providers fail to identify retroactive Medicaid eligibility, they miss opportunities to bill for services rendered.

How Automated Medicaid Monitoring Works

Automated insurance discovery runs a scheduled check regularly (likely at the beginning of each month), reviewing patient rosters for retroactive Medicaid coverage and identifying billable insurance up to three months before the date of service. Automated Medicaid monitoring solutions continuously track changes in Medicaid eligibility, alerting providers when new and/or retroactive coverage is available.

A good Medicaid monitoring tool can also identify nuances, like if partial coverage turns to full or traditional care turns to managed care (or vice versa in either of these scenarios). It’s a simple, hands-off process that double-checks accounts for coverage, and it can patch the stubborn Medicaid leak in your revenue cycle.

Benefits of Medicaid & Insurance Monitoring for Providers

Insurance discovery helps capture more reimbursements from Medicaid (and other insurers as it runs an exhaustive check of all government and commercial payers. It also flags accounts with retroactive Medicaid coverage eligibility, ensuring providers receive the maximum reimbursement for covered services.

Running automatically in the background reduces manual work throughout the billing and claims process. Manual insurance verification takes time and is prone to human error. Automated Medicaid monitoring eliminates the need for staff to track coverage changes manually, freeing them up to focus on more rewarding tasks.

How Office Ally’s Insurance Discovery Tool Monitors Medicaid Coverage

Office Ally’s insurance discovery tool is designed to identify and flag unknown Medicaid coverage, helping providers capture retroactive eligibility, reduce denials, and secure reimbursements. Office Ally ensures providers capture all available payments by leveraging automated tracking and real-time eligibility verification. Our insurance discovery tool offers:

• Comprehensive coverage discovery and monitoring
• Customizable workflows
• High accuracy, low false-positive rates
• No implementation requirements

Get Started with Office Ally’s Insurance Discovery tool

By integrating insurance discovery tools into revenue cycle management, providers can ensure they never miss an opportunity to bill Medicaid for eligible services. Contact Office Ally today to learn how your organization can benefit from automated Medicaid monitoring.