How do you know if your ELIGIBILITY PROGRAM is operating at 100% efficiency?

To find out, answer these three questions:

• Do the same eligibility team members assist self-pay patients with Medicaid applications AND also work disability cases?
• Do you compensate the eligibility team the same for Medicaid awards as well as disability awards?
• Is eligibility team performance evaluated solely on awarded Medicaid billings?

If your answer is “yes” to any or all of these questions, you are very likely NOT capturing disability opportunities for your self-pay patients, and therefore leaving significant money on the table.

Explanation:

• Assisting self-pay patients with Medicaid enrollment, requires a much different skillset than working disability cases. Medicaid applications require an in-depth knowledge of recognized Medicaid groups. If the patient meets the criteria for Medicaid, for instance: FEMALE/PREGNANT/LOW INCOME, then the enrollment process is relatively simple. Working a disability case is different. You must prove to the Social Security Administration (SSA) that the individual is disabled, and therefore unable to work. This requires: some detective work in identifying the “onset of disability” in the health record; it requires analytical skills to overlay work history, demonstrating unemployment AFTER “onset of disability,” and finally, you need legal advocacy skills to appeal denials, and represent patients at ALJ hearings.
• Because there is a medical component to working disability cases. And because the SSA is diligent in weeding-out fraud, each disability case requires substantiating evidence supporting the disability claim. The eligibility team also needs an in-depth knowledge of what the SSA requires for awarding SSI (Medicaid) or SSDI (Medicare). Finally, the eligibility team must respond to multiple requests for more information, documentation – and then be in a position to appeal denials by the SSA. Altogether, it (conservatively) takes 3-5 times longer to work a disability case than a Medicaid case. If the eligibility team is compensated (or evaluated) the same for both Medicaid as well as disability, the team will be much less likely to work disability cases.
• If your hospital tracks eligibility team performance at all, it probably just looks at total Medicaid billing attributed to the team. This provides a very incomplete picture of performance. Disability cases that were not pursued would NOT show up using this methodology. At the very least, eligibility “Key Performance Indicators” (KPIs) should include (1) Medicaid applications and awards/billings, (2) SSI protected filings and awards/billings, (3) SSDI applications and awards/billings. There is no magic ratio for Medicaid vs. SSI vs. SSDI cases. This will vary from hospital to hospital. But if disability is represented by just a “handful” of awarded cases – you are very likely NOT capturing all disability opportunities. And if this is not showing up on a performance report, there is no reason to do so.

Mike Vana
Associate
QUALITY REIMBURSEMENT SERVICES, INC.
(917) 592-5802
mvana@qualityreimbursement.com