Simplifying Texas Medicaid Claims with RPA

MaryBeth Folger News

Simplifying Texas Medicaid claims with RPA

Learn how HPA helped eight managed care organizations implement RPA to comply with evolving regulations and secure their Medicaid contracts with the State of Texas. Read the case study.

The Medicaid program in the United States is administered through the U.S. Department of Health and Human Services through Centers for Medicare and Medicaid Services (CMS). CMS establishes the program requirements and monitors each state’s program to ensure their compliance. States are required to follow the CMS protocol for service quality and eligibility standards, a responsibility that most states contract to health insurance companies.

A provision of the Affordable Care Act called for expansion of Medicaid eligibility in order to cover more low-income Americans. With this expansion, the federal government would cover 90% of the cost for the state. As part of a Supreme Court ruling in 2012, states cannot be forced to expand their programs; 14 states have opted against expansion.

Texas, one of those 14 states, has the largest Medicaid coverage gap in the country, with roughly 1.1 million residents falling outside of the state’s eligibility requirements. In 2011, the state was able to negotiate a Medicaid 1115 waiver, a five-year agreement that secured $25 billion in federal funding, which is set to expire in 2021. The funding has allowed the state to expand Medicaid managed care while preserving hospital funding, provide incentive payments for healthcare improvements, and direct more funding to hospitals that serve large numbers of uninsured patients.

As part of this waiver, the state must adhere to federally-mandated terms and conditions to prove they are working to reform their healthcare delivery system while also maintaining quality of care. Adherence to these guidelines has proven challenging for the managed care organizations (MCOs) which have contracted with the State of Texas for Medicaid business. To add to the complexity, the sheer population size of Texas Medicaid members results in a large volume of claims to be processed, often retroactively. This creates a burdensome operational constraint for MCOs, which need to staff up quickly to process claims within a specific timeframe, or reconfigure their claim management systems to meet these unique requirements as they roll out.

Eliminate the operational challenges created by Medicaid claims

The nature of Texas Medicaid claims has caused many health plans to seek out robotic process automation to comply with the ever-evolving state and federal requirements while also ensuring their Medicaid business is secure.

Today, HPA is automating Texas Medicaid claims for eight MCOs contracted with the State of Texas. Our automation specialists researched Texas Medicaid requirements and worked with the clients’ subject matter experts to build out the process requirements, as well as address the configuration limitations within their claims management system.

Long Term Services & Support (LTSS)

LTSS claims are submitted in both high-volume and frequency, due to the nature of services being rendered. A state-mandated change in billing requirements shifted each unit of service from one-hour increments to 15-minute increments. On top of this, the contracted pricing of these claims is dictated by the service modifiers and many platforms still do not allow for complete customization on all modifier combinations.

One client, in particular, faced a tough decision without automation: hire 19 employees to manually process the claims, or pursue a three-year custom IT solution. Due to the timely filing and minimum processing accuracy requirements, the client couldn’t afford the increased cycle time and inaccuracy that comes with manual claims processing. HPA’s automation experts built out custom pricing tables so that claims could easily be processed according to the new billing requirements, without customization to its system.

HPA was also able to quickly process the client’s inventory of 50,000 pended claims, well ahead of the 30-day deadline. Over the last three years, HPA has processed more than 500,000 LTSS claims, offsetting more than 30,000 hours of manual processing tasks.

LTSS Electronic Visit Verification (EVV)

EVV is a computer-based system that verifies the occurrence of authorized personal attendant service visits by electronically documenting the precise time a service delivery visit begins and ends. As part of the 21st Century Cures Act, CMS requires EVV for all Medicaid personal care and home health services, a responsibility that falls to the MCOs. HHSC negotiated delays to the EVV start date for new programs, services, and service delivery options affected by the Cures Act, meaning more operational changes for MCOs. In order for these payers to process claims for Medicaid services currently included in EVV criteria, additional fields on the claim file were required that did not exist within the claim management system, a change that would require custom configuration.

HPA’s robots utilize the claim file from the EVV portal to supplement the missing fields and process the claims, allowing clients to comply with new requirements without operational impact or system configuration.

Download the case study to continue reading.