Medicaid

Medicaid Redeterminations and their Impact on Payment Integrity and COB

At the beginning of the COVID-19 pandemic, Congress enacted the Families First Coronavirus Response Act (FFCRA), which required Medicaid programs to keep members continuously enrolled through the end of the public health emergency (PHE) in exchange for enhanced federal funding.

That continuous coverage ended on March 31, 2023, and while states are staggering their redetermination processes and following different timelines, here is what we know based on latest data:

At least 5.5 million Medicaid enrollees have been disenrolled as of August 29, 2023, based on the most current data from 47 states and the District of Columbia.
74% of all people disenrolled thus far have had their coverage terminated for procedural reasons, many of whom may still be eligible for Medicaid coverage.
CMS paused redeterminations in six states due to various procedural barriers.
It is expected that disenrolled Medicaid beneficiaries will choose employer-sponsored health plan coverage.

The Impact of Redetermination on Coordination of Benefits and Payment Integrity

As the unwinding of the PHE continues and redeterminations proceed, total Medicaid enrollment will almost certainly continue to decline. If the loss of coverage is on a healthier population, the cost of care on the remaining Medicaid population will go up, resulting in higher medical loss ratios for health plans and requiring proactive payment integrity to manage and reduce costs.

With about 74% of disenrollments related to procedural issues and disenrolled members potentially reenrolling, the cost and impact of managing denied claims will be high. Further, this scenario will increase churn, wherein enrollees disenroll and re-enroll within a short period of time, resulting in higher administrative costs.

For those disenrolled Medicaid beneficiaries choosing employer-sponsored health plans, finding and verifying other coverage details will be important.

Managing these challenges without the right technology platforms, automation, and use of artificial intelligence will be nearly impossible and cause exponential administrative challenges for health plans.

ClaimShark

Our payment integrity orchestration platform enables health plans to command and control every aspect of their payment integrity operation so that they can identify and recover more overpayments and increase cost avoidance.

AuditShark

Our payment integrity audit platform equips health plans with the automation and tools they need to effortlessly cost-avoid COB overpayments and detect overpayments themselves, so that they can maximize savings at the lowest possible cost.

The results speak for themselves. Clients using ClaimShark have experienced up to a 2X improvement on overpayment recovery and savings while those using AuditShark have seen a 4X improvement in productivity and a 10X return on investment.

Learn more about ClaimShark and AuditShark or contact us for more information