Discover and Document Medicaid Eligible Days to Navigate Unwinding

April 17, 2023

Medicaid Unwinding|

Why Medicaid unwinding is happening

As pandemic emergency measures wind down, Medicaid coverage is unraveling for an estimated 10-15 million Americans. While the Families First Coronavirus Response Act has prevented patients from losing Medicaid coverage since 2020, the continuous Medicaid coverage protections have begun to expire as of April 1 with dates varying by state. The massive loss of coverage is getting the name “Medicaid Unwinding.”

Not only will the loss of Medicaid coverage affect patients who no longer qualify but it also comes with major implications for health systems, providers and insurers. Health systems will now have to overcome new compliance challenges, track Medicaid eligible days to optimize Disproportionate Share Hospital (DSH) payments and determine eligibility for those who desperately need care.

How Medicaid unwinding impacts providers

If health systems do not prepare for Medicaid unwinding, they risk significant consequences including:

  • A significant decrease in Medicaid and Medicare DSH payments, which can amount to millions of dollars
  • Lower Medicaid payments for services due to eliminated eligibility
  • Potential loss of 340B eligibility

Compliance teams have likely been working to ensure that their organization is ready for the Medicaid Unwinding. However, organizations need a multi-dimensional approach to address this issue. They must take special care from intake, during episodes of care, and through discharge and billing to optimize care for the patients and payment for the care provided. Plus, health systems must follow all relevant regulations and coding requirements, which will be changing on the fly.

Finding and tracking Medicaid days is already a complicated process with ample opportunity for errors, with up to hundreds of codes and categories. Because of Medicaid Unwinding, states will likely enact new codes for eligible Medicaid patients. Even more, the codes vary by state. These changing codes make it confusing to identify appropriate Medicaid days which could lead to millions of dollars lost in DSH payments.

Recommendations by experts

Even if health systems understand changing codes and eligibility qualifications, the variance by state presents problems. For example, if your health system borders a state line or is located in a high-traffic tourism or medical destination area, you will have to understand varying state rules and regulations that need application along with your current state. This daunting task can be difficult to prioritize, especially with staffing and labor shortages.

When faced with hiring additional nursing care staff or hiring financial staff to manage the new Medicaid rules and regulations to maximize DSH payments, health systems will likely choose care first… and rightfully so.”

Lawrence Millner, Ph.D.,

Director of Medicare Reimbursement

Instead of hiring a full-time employee, an outside partner can help you navigate the changing landscape.

For example, you can partner with specialized staff who understand regulatory codes state by state to help you identify more Medicaid eligible days. Additionally, solutions exist with proprietary rules and algorithms to quickly process large volumes of data while ensuring compliance with changing regulatory and Medicare Administrative Contractor (MAC) requirements.

Medicaid Unwinding also presents significant eligibility concerns. Health system staff should talk to Medicaid patients to verify information on their Medicaid cards as soon as possible. Having the correct address, name, and information will help ensure eligibility when your state completes the Unwinding. If any details are incorrect, the patient’s eligibility is at risk. Get help cross-checking in-patient and out-patient information to identify eligibility errors in order to provide more patients with vital care.

Learn more about using Disproportionate Share Hospital services to help your health system optimize Medicaid eligible days with a full-service solution that utilizes highly skilled auditors and powerful AI to accurately capture more DSH reimbursement.

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