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A nightmare for both Healthcare Providers and Medicaid Enrollment Analysts

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Providers are struggling – Providers face a tough challenge in filling paper applications costing weeks and even months due to the increasingly complex eligibility and documentation requirements. The inherent complexity often leads to large percentage of deficiencies and rejections due to errors and omissions. Portals where available remain simple and static and are often less preferred than paper due to severe limitations. Since the enrollment processes remain manual there is no visibility into the processing status leaving the providers uncertain and unhappy. Providers make between 3-5 calls to a call center per application submitted. All of this leads to high volume of calls for preparation support and status inquiries. It is estimated that as much as 20% of applications are abandoned before submitting and another 10% post-submission due to the frustration associated with this complexity and delays. Separate and disparate credentialing for each Managed Care plan puts enormous burden on providers in cost, time and complexity impacting access to care. In light of the acute provider shortage the situation is especially untenable. Also, once the application is submitted there is poor visibility into the process increasing anxiety and low provider satisfaction. Providers also remain non-compliant not knowing when to file a supplemental change or an affiliation for a rendering provider that joins their group or facility.

So are the Medicaid Enrollment Analysts…

The effectiveness of government health programs such as Medicaid and Medicare has been marred by constant reporting of fraud, patient abuse and neglect by small population of enrolled providers. Now, the new compliance is mandating the states to focus on “Prevention” by enabling comprehensive screening and ongoing monitoring. State Medicaid agencies face considerable challenges in implementing these
regulations while getting them right. These regulations require expanded data collection and more frequent revalidation of existing providers. Enrollment workload is now expected to triple over the next three years. Existing manual enrollment processes cannot scale making this task all but impossible. Also, the current systems lack important capabilities to record observations contextually, collaborate with internal and external stakeholders digitally and leverage system enabled intelligence to augment human decision making. As a
result, processing times are long and decisions are based on limited external verification.

Automation is no-longer optional

With the federal regulations redefining traditional provider credentialing, Providers now need to be screened against nation wide databases
including hundreds of sanction lists across state and federal agencies. It is critical that the screening is risk-based which means states need to risk score providers including background checks for high risk entities much like in the banking industry. And it is no longer sufficient to screen providers once at the time of enrollment, instead it is required to monitor monthly for ongoing compliance and full re-validation every three to five years. States are struggling with implementation as revised screening guidelines means 10X increase in workload. Current screening processes which rely on manual lookups can no longer scale to meet this need.

Even a small state with 20, 000 providers would need to perform 4 million checks annually to comply with the new federal regulations

Medicaid requires a smart and modular system that could make the entire process of Provider Lifecycle Management (PLM) a completely paperless exercise while seamlessly complying with federal and state Medicaid regulations. Medicaid requires an intelligent system that could bring about work-life balance to both Healthcare Providers and Medicaid Enrollment Analysts.

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