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Ensuring payment from out-of-state Medicaid agencies and thier allied Medicaid Managed Care Organizations (MMCOs) can be an arduous task.
Requirements for provider enrollment and applications for patient
eligibility vary among agencies, their allied MMCOs and other insurance providers. Each state and carrier has different
claims processes, procedures and regulations. Many state Medicaid agencies employ MMCOs managed
care programs, often making the process even more convoluted.
Kent applies over 35 years of experience,
extensive know-how, prompt follow-up, and meticulous verification
procedures to overcome these hurdles to payment from out-of-state
insurers and Medicaid agencies. Using our fine-tuned Best Practices for Reimbursement,
we manage enrollments, applications, and claims to out-of-state insurers
and Medicaid agencies, freeing our clients to concentrate on other, more important issues.
Out-of-state Provider Enrollment
The first step in securing payment from out-of-state
organizations is to ensure that the healthcare provider is credentialed
and enrolled by the particular insurer or Medicaid agency. Kent
drives the process, by securing all necessary documentation, completing and submitting all provider enrollment
applications and procuring the information needed for all required attachments, including:
• Certificates of insurance
• JCAHOs
• Licenses
• Completed W-9 forms
• IRS certifications
• CLIAs
• Medicare EOBs (remittance)
• DEA certifications
• Board of directors/trustees lists
Out-of-state Medicaid Applications Program
In situations where a patient is potentially
eligible for out-of-state Medicaid coverage, our Applications team
seeks the highest level of benefits and the earliest possible retroactive eligibility start date
for the range of services needed, including community-based programs,
disability coverage, and long-term care placement, if appropriate.
For clients whose patients may be eligible
for out-of-state Medicaid payments, we:
• Communicate face-to-face, over the phone, and through correspondence
with patients, their families, and healthcare providers
• Enroll patients with the appropriate primary care physician/clinician
• Communicate through memoranda and conferences with staff
at out-of-
state Medicaid enrollment centers and agencies
• Issue medical and psychological consultation exam reminders
• Request and prosecute fair hearings
• Perform legal reviews and file complaints with the courts,
when necessary
• Retrieve and submit medical records to out-of-state agencies,
as required
Kent handles all aspects of applying for
out-of-state Medicaid eligibility. We screen patients, file and
track applications, and manage all aspects of appeals and denials.
Screening
Kent offers extensive screening services
that allow us to determine potential eligibility and collect any
required additional information. Our trained specialists speak Spanish
and Portuguese and work closely with interpreter services to meet
patients’ needs for translation. They carry out interviews
on site; they can also screen over the telephone or through correspondence,
when that is more convenient or appropriate. In many cases, they
pre-screen cases for potential eligibility, often even before services
are rendered.
Submissions
If we deem that a patient is potentially
eligible for Medicaid in another state, we use the information collected
in the screening process to file an application. We monitor applications
carefully, using our automated collection/tracking/scheduling system
to coordinate all procedures and timelines.
Denials and Appeals Management
When an out-of-state agency denies coverage
that should be available per state or federal guidelines, Kent responds
efficiently and effectively. We immediately file an appeal, as appropriate,
to preserve the original application date and potential retroactive
eligibility. This approach ensures that our clients do not miss
out on any reimbursement opportunities.
Out-of-state Claims Management
Kent’s Claims team ensures complete,
accurate and timely processing of claims to out-of-state commercial
and government insurers. We can:
• Handle issues specific to inpatient and outpatient services
• Verify patient eligibility and coverage dates
• Investigate and resolve issues that arise out of Medicaid
eligibility
verification system restrictions
• Pursue claims with all out-of-state Medicaid managed care
organizations
• Request retroactive and prior authorizations
• Request and provide medical records to agencies as appropriate
• Ensure consistency and accuracy of universal billing and
claims correction
forms
• Ensure consistency and accuracy of diagnosis and procedure
codes
• Resolve issues with primary care physician/clinician referrals
• File appeals with appropriate out-of-state agencies
• Challenge medical necessity claim denials
• Request administrative hearings, as necessary and appropriate
Kent manages out-of-state claims using a
well-defined process that involves claims submission, claims tracking
and reporting, denials and appeals management, and legal follow-through,
as necessary.
Claims Submission
In the event that a patient falls under the
auspices of an out-of-state organization, Kent follows the same
assumption as we do for any other insurer or government agency:
"A Clean Claim Gets Paid."
Before we submit any claim, we ensure
the completeness and accuracy of all information. We verify eligibility,
authorization, referrals, coding, medical records, hospital clinical
notes, and proof of facsimile submissions. As often as possible, the office
uses electronic means to send off referrals, claims, forms and other
information, facilitating efficient and cost-effective execution.
Claims Tracking and Reporting
We manage all our efforts with an automated
collection / tracking / scheduling system in real time. Our clients
can access the system to see exactly where claims stand.
Custom reports give our clients extraordinary
insight into general trends, granular details, and tactical and
statistical information. Kent managers review reports regularly,
looking for ways our clients can improve their own claims processing.
At no extra cost, we recommend remedies and provide in-service training,
showing clients how to avoid these problems.
Denials and Appeals Management
Healthcare providers lose hundreds of thousands
of dollars of potential revenue simply because it is so difficult
to process out-of-state claims correctly. Kent handles denials by
preventing them in the first place. Before a claim is submitted,
our specialists discover and rectify potential problems caused by
incomplete or inaccurate forms, billing deadline discrepancies,
coding errors, and lack of referrals.
If an out-of-state insurer or agency denies
a claim, we immediately notify our client of the result and its
reason. If the denial is unjustified, our appeals specialists resubmit
the claim with the corrected and amended information.
Legal Follow-Through
In the rare cases when standard appeals procedures
are unsuccessful, our staff attorneys are available to advocate
and negotiate. As members of both the Massachusetts and New Hampshire
Bars, they have the qualifications to request and prosecute fair hearings, file
complaints for judicial review with the appropriate court, and appeal
claims to the highest level in both jurisdictions. These capabilities
make us unique in the industry.
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