Medicaid disenrollment highlights need for increased automation

WASHINGTON – HME providers might feel like they’ve been “whipsawed” by the current Medicaid disenrollment, but there are tools and processes they can implement to continue business as usual, say industry stakeholders. 

As of Aug. 1, 2023, states have disenrolled at least 3.8 million Medicaid recipients based on the most current data from 41 states and the District of Columbia, according to Kaiser Family Foundation (KFF). 

“There’s a lot of whipsawing going on right now and the best defense is a good offense,” said Andrea Stark, a Medicare consultant and reimbursement specialist for MiraVista.  

Continuous enrollment in Medicaid, a policy put into place during the public health emergency, ended March 31, 2023, setting off waves of disenrollments by states, starting with Arizona, Arkansas, Idaho, New Hampshire and South Dakota in April. 

The single biggest tool a provider can use to manage disenrollment is auto eligibility checks, with an emphasis on the auto, Stark says. 

“It’s critically important for providers to know where the patient stands with eligibility, and it’s critically important for the process to be automated,” she said. “Otherwise, they’re taking employees offline and slowing down the order confirmation and other processes. If they can get a computer to do the checks en masse, it’s worth it, because there are so many moving pieces.” 

A process that needs to be in place during disenrollment: Verifying eligibility not only at intake but also before delivery, especially for complex rehab wheelchairs, where the funding cycle can be lengthier. 

“In general, providers need to be more inquisitive,” said Laura Williard, vice president of payer relations for AAHomecare. “Instead of just taking that hospital discharge sheet with a Medicaid patient on it, dig into it before accepting it as reality.” 

Both Stark and Williard see the disenrollment as an opportunity for growth – for providers and for state Medicaid programs. For providers, they can be a key interlocuter between patient and payer. 

“We’re in the homes; we’re talking to patients,” Williard said. “We can help them more than a doctor that they might see every six months or a year or not at all. How is this another opportunity for us to be a good partner?” 

For state Medicaid programs, the disenrollment is a good lesson on why automated processes are needed for smooth transitions, Stark says, especially since 74% of all patients disenrolled had their coverage terminated for procedural reasons, according to KFF. 

“They can pull in addresses from SNAP and enrollments from WIC to help determine eligibility,” she said. “If patients qualify for these programs, they qualify for continued Medicaid assistance. They can even take advantage of the National Change of Addresses system. A lot of states haven’t encountered as big a process as they’re experiencing with this and, hopefully, it will spur more automation within the Medicaid systems.” 

For its part, CMS has not been blind to the challenges and has recently introduced some flexibility into the process, Williard says. For example, the agency has designated pharmacies, community-based organizations, and/or other providers as qualified entities to make determinations of presumptive eligibility on a modified adjusted gross income basis for individuals disenrolled from Medicaid or CHIP for a procedural reason in the prior 90 days (or longer period elected by the state). 

“I am (highlighting) this one for the National Association of Medicaid Directors to see if we can help,” she said.