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  • Writer's pictureEligibilityOneᵀᴹ

Out-of-State Medicaid Reimbursement: Top Challenges & Solutions

Out-of-state Medicaid reimbursement poses significant challenges to healthcare facilities. Many choose to write off these difficult claims. Those that attempt to work them experience success rates so low, they don’t seem worth the effort.

Fortunately, you don’t have to lose out on this valuable revenue.

Below are the top challenges to out-of-state Medicaid reimbursement along with the ways in which EligibilityOne can help you solve them.

Challenge: Changing Regulations

EligibilityOne has expertise in each Medicaid program and can help solve your challenges to out-of-state Medicaid reimbursement.

It is very hard for an internal billing team to keep track of all the rules governing Medicaid because they are continually modified and vary from state to state. Each state, U.S. territory, and Washington, D.C. has a separate Medicaid program with its own requirements and processes. If you do manage to find an employee with this niche expertise, an additional challenge arises in retaining the employee or retraining someone else if you face turnover.

Solution: EligibilityOne provides a team of experts who specialize in out-of-state Medicaid and every unique Medicaid program while staying up-to-date on all new laws and policies.


Challenge: Enrollment of Facility AND Providers

Before you can submit a claim to Medicaid, you must enroll your facility and providers in the specific state’s program you are billing. This is a very involved task as it typically requires gathering sensitive personal information (e.g. social security numbers, home addresses, copies of driver’s licenses, signatures) from each of the hospital’s board members and/or physicians. Even ordering, prescribing, and referring (OPR) providers for Medicaid patients must complete OPR provider enrollment.

Enrollment must be completed in a timely manner so that you don’t miss your window for reimbursement. The enrollment process and which documentation each program requires for enrollment differs by state, further adding to the difficulties. In fact, may healthcare organizations consider this the most painful step on the road to out-of-state Medicaid reimbursement.

Solution: EligibilityOne completes, submits, and maintains your facility AND provider enrollment applications at no additional cost to you. Save yourself the money, time, and headache it takes to accomplish this job and simply let us do it for you.


Challenge: Billing & Follow-Up

The billing process for Medicaid also differs by state. Each program has its own claim forms, billing requirements, list of covered services, and reimbursement rates. Even a simple error like using the Medicaid billing template for your own state to submit a claim to another state’s program can result in a denied claim.

Your billing team will need to devote time to follow up on delayed or denied claims, sometimes unaware of why the claim was initially rejected.

Solution: The EligibilityOne out-of-state Medicaid team has experience in all 50 states’ billing procedures. We will bill and follow up on each out-of-state Medicaid claim for you, ensuring no claim is neglected, as well as take care of the appeals process for any denied claims when necessary. Not only are our team members specialists in claims resolution for Medicaid and out-of-state Medicaid, but our Medicaid expertise and pre-arrival workflow solution also prevent errors and issues that cause denials, underpayments, and reimbursement delays in the first place – providing you with higher remittance and quicker reimbursement.


Challenge: Maintaining Qualifications & Revalidation

For each Medicaid program you wish to bill, your facility must maintain its qualifications according to the program’s requirements and your providers must complete periodic revalidation with the program(s). Failure to do so will result in deactivation with the Medicaid program and denied claims. If a provider is un-enrolled, re-enrollment will entail more time and work and there may be a gap in eligibility for reimbursement.

Solution: EligibilityOne provides maintenance and monitoring of all your Medicaid credentials to prevent expirations and deactivation and to make sure you are proactively maintaining compliance with each program.


Challenge: Drain on Resources

Each of these challenges requires time, expertise, and resources that your staff may not have or that they cannot afford to take away from their other billing responsibilities. Focusing their attention on out-of-state Medicaid reimbursement is not the best use of their time and your money if they do not collect a sufficient volume of revenue.

Solution: EligibilityOne is a performance-based extension of your revenue cycle team. Our services are strictly contingent, meaning we don’t get paid until we’ve delivered on our promise to get you paid. The revenue we bring in will always exceed the cost of our services and your employees can focus on other objectives while we manage your complicated out-of-state Medicaid work.

Solve Your Out-of-State Medicaid Reimbursement Challenges with EligibilityOne


Outsource out-of-state Medicaid work to EligibilityOne and we will take on these challenges for you. No longer will you need to assign time, energy, stress, and staff to these complex claims or write them off as bad debt.

We will handle all aspects of out-of-state Medicaid enrollment, billing, and follow-up for you, so you don’t miss out on this substantial source of revenue. Contact us today and start collecting the out-of-state Medicaid reimbursement you are due!



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