MassHealth Applications Programs

The process of applying for MassHealth eligibility can be an administrative black hole unless providers have the resources in every department of the organization to provide the right information at the right time. By submitting and tracking timely and accurate applications, PV Kent & Associates makes it easier for healthcare providers to obtain eligibility through the Office of Medicaid.

In situations where a patient is potentially eligible for MassHealth, we seek:

• Community program coverage
• Basic program coverage
• Essential program coverage
• Disability program coverage
• Long-term care program coverage

• Commonwealth Connector program coverage

Our goal is to secure eligibility for the highest level of benefit and the earliest possible start date for which patients qualify. As a result, our clients realize the maximum level of reimbursement for the services they provide. We constantly refine our Best Practices for Reimbursement to achieve these goals.

Kent’s MassHealth Application Services
Here at Kent, we tailor our MassHealth applications processes and procedures to meet each client’s specific needs. For example, healthcare providers turn to us to:

• Communicate face-to-face, over the telephone, and through

   correspondence with patients, their families and healthcare providers
• Enroll patients with the appropriate primary care physician/clinician
• Communicate with MassHealth Enrollment Center staff through memoranda

   and informal conferences
• Issue medical/psychological consultation exam reminders
• Request and prosecute fair hearings
• Perform legal reviews and file complaints with the appropriate agency or

   court, when needed
• Retrieve and submit all necessary documentation, including medical records,

   when necessary

Screening
As soon as a provider refers a patient to us, we start the screening process. We can even prescreen cases for potential eligibility, often even before patients begin to receive care. Our trained specialists speak Spanish and Portuguese and work closely with interpreter services to meet patients’ needs for translation. They carry out interviews onsite, or they can communicate over the telephone or by correspondence, when that is more convenient or appropriate.

In some cases, Kent determines that a patient has no other coverage available and does not qualify for Medicaid or Commonwealth Connector benefits but still meets the federal poverty guidelines for free care eligibility through the Massachusetts Uncompensated Care Pool (UCP). In these instances, our specialists provide our clients with the documentation necessary to support the write-off to the UCP.

Occasionally, the information we gather demonstrates that an applicant is not categorically eligible for services from MassHealth, the Commonwealth Connector or UCP. In these instances, we immediately notify the provider of this outcome, returning the referral with a comprehensive written explanation as to why the application failed to meet applicable program guidelines.

Submissions
If we deem that a patient is potentially eligible for Medicaid, we use the information collected in the screening process to file an application for MassHealth, Commonwealth Connector, and/or UCP coverage. We submit most applications via the MassHealth Virtual Gateway; we can also send hardcopy applications, as the circumstances warrant.

Unlike many other firms, many of which simply submit applications and hope for the best, we monitor each application through every step of the process and perform all necessary follow-up to successfully complete the application process. Our Applications department takes advantage of our automated collection / tracking / scheduling system to coordinate all processes, procedures and timelines — in real time.

Denials and Appeals Management
Most healthcare providers that submit MassHealth applications without assistance experience on average a 50-60% rate of approval for MassHealth applications. Our average rate of approval is consistently in the high 70% to 80% range. In addition, Kent attorneys have a better than 95% success rate in reversing (and avoiding) many of the most common erroneous administrative denials.

MassHealth regulations are often in a state of flux. We stay up-to-date with changes in the controlling regulations and appeal procedures. We consistently and aggressively appeal denials that arise from the inadvertent failure to follow applicable rules and regulations. We also address denials caused by agency limitations — such as inadequate staffing — which lead to processing delays and inevitable administrative mistakes. In short, we increase our clients’ chances of being paid for care that would often otherwise go uncompensated.

When MassHealth denies coverage that should be available per agency guidelines, Kent responds efficiently and effectively. We immediately notify the healthcare provider and file an appeal, as appropriate, to preserve the original application date and potential retroactive eligibility. This approach ensures that clients do not miss out on any reimbursement opportunities.