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HEALTH

STEERING PROVIDER IN MEDICAID

5 Mins read

Understanding Patient Needs

Healthcare is more than healing physical symptoms for the sick. Health includes the mind, spirit, and social factors. There are so many social factors that you must consider when treating your patients, such as homelessness, lack of food and transportation, and no support. A person’s spiritual being is the missing piece for most.
When a patient arrives in your clinic late, what is the first reaction from you and your staff? Naturally, it would be an aggravated state. Let us stop and think about the circumstances the Medicaid population faces every day. The last study showed 2.1 million Medicaid enrollees were without transportation and primarily lacked medical care. There is a solution to transportation that most providers and patients are unaware of; Medicaid offers free transport to and from healthcare appointments. This information is available through your state’s Medicaid programs, ask your Medicaid Managed Care Organization (MCO) provider relation representatives. 

We all know the angry patient who disrupts your office and curses your staff but is friendly to you or maybe not. Instead of suddenly calling the police or labeling them as having a mental condition, think about their social structure. Take the time to ask that patient about their current situation in life. Most of the time, you will find the angry patient has lost a job, family member, or even in an abusive relationship, and these are the symptoms of calling out for help. There are free counselors in your area for low-income families, just do a little bit of research on the internet. It may help to have a list of social determinants and a staff member with counseling abilities and solutions to meet patient needs. 

Let us not forget about that homeless mother with hungry children. This one is difficult to recognize most times and pride gets in the way. It is necessary to build a great relationship with your patients and make them feel safe with you and your staff. A friendly, nonjudgmental environment is the way to create a tremendous secure experience for patients. Once a patient confides in you, then make sure to have the answers to the resources they need.  

The purpose is to focus on patient needs beyond their medical needs. Think about expanding your services by adding a clothing closet, food pantry, transportation bus, or counseling services. The best way to execute this is to partner with organizations in your area. Nonprofits help communities and local businesses. 

Provide Quality Care

Providing quality care involves knowing your patient’s needs, goals, and offering services to meet them. Goals are powerful in improving a patient’s health. For goals to be successful, the patient must understand their current health status, the value behind the result and the patient must be the one to set SMART goals. Specific, Measurable, Attainable, Realistic, and Trackable goals need to be clear and appealing to the patient and their health. Involving the patient’s support system, such as family and friends, is vital to their success. 

Sitting at the pharmacy is not ideal for anyone, especially to a low-income patient that has kids or no transportation. Use your electronic medical record (EMR) system to submit prescriptions to the patient’s pharmacy, so the medicine is ready by the time they arrive. Better yet, build a clinic near a pharmacy or build a pharmacy in your clinic. If you do not want the hassle to have a pharmacy, then understand your state’s regulations to offer medications from your clinic and meet those minimum requirements. Some states will allow providers to have over-the-counter drugs. Most Medicaid patients cannot make it to the pharmacy, so having medicines on-hand to give them before they walk out the door is the best solution. 

Do not forget about your patients. Providers do not purposely omit patients, but in a high-volume clinic, it is easy to send patients off the grid. Put systems in place with your staff to follow up with each patient to make sure there are no barriers for them to meet their goals, and they have resources. Hiring a dedicated quality nurse would help improve quality care. Quality is more significant than quantity when it comes to patient care. 

Providing extended services and hours will reduce fragmented care. Medicaid is not a popular insurance carrier among providers, especially specialty providers. Offering extended services in your clinic will help you manage conditions common to your community and guarantee quality care for families. Increase your services with x-ray, ultrasound, labs, ECG, and even minor surgical procedures. If there are multiple providers involved in a patient’s care, make sure to coordinate care for the best results. Communication with the patient, patient family, and other providers is key to coordinating care. 

Doing everything right and still not getting paid

We all must admit that getting paid by Medicaid is not easy at times, and they offer a low fee schedule. But you can be successful in a Medicaid community. First, read your contracts clearly and understand your fee schedules before providing services. Secondly, realize the Medicaid population are people and not a quick-rich paycheck. Third, build relationships with your MCO provider representatives, state Medicaid office, and Medical Associations. They are all your allies, not your enemy. 

Follow the processes of getting paid. Educate your billing staff on using the right billing codes. If everything is followed and correct but still cannot get paid, then the last resort is filing a claim to your state’s Insurance Commissioner or Medicaid Officer. Yet, no resolution then report to your state’s Medical Association or legislators. Medicaid MCO plans do not like being reported to the state or associations. Therefore, once you establish your authority and build an anti-bully reputation with them, then they will be happy to work with you. 

Keep a timeline of their changes. Health insurance carriers make changes or updates about two times a year. During these times, you should expect more denials and ludicrous coding changes. Understanding this will help you prepare financially and mentally on how to handle your income and demeanor until you get paid again.

The best thing about healthcare reforms and serving the Medicaid population are the incentive programs. The Medicaid program will offer many different types of incentives that can help you with Quality Improvement and Boost Revenue. Make sure to decline any applications that you cannot terminate, they cost you more money without a return, or they take money back from you. A few notable programs are Meaningful Use and Patient-Centered Medical Home. These programs improve quality and supply extra income to providers who navigate them well. They also offer free advisors to provider offices to become successful.

Summary

Develop a resource brochure to meet your population’s social determinants. Build a relationship with your patients and provide a safe clinical experience with the right staff. Meeting your patient’s needs is just as important as healing them. Quality improvement should be every provider’s goal for their community. Expanding services, developing a robust visionary team, and building a clinic around community needs is key to quality. Build relationships with insurance carriers, provider relations, state commissioners, and medical associations. Believe it or not, they all want providers to succeed. Do not become overwhelmed with regulations and claim denials because there are ways to navigate them with the proper education. Update your policies and procedures to employ successful business practices throughout your organization.  

If you need more information or to inquire about healthcare consulting, please email me at healthcarebusinesscounseling@gmail.com or find me on LinkedIn.

References

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6150917/
https://www.macpac.gov/wp-content/uploads/2019/05/Medicaid-Coverage-of-Non-Emergency-Medical-Transportation.pdf
https://www.goodtherapy.org/learn-about-free-counseling-and-affordable-therapy-options.html
https://www.modernhealthcare.com/patient-care/year-review-healthcare-makes-bigger-strides-address-social-needs
https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/setting-smart-goals
https://www.verywellhealth.com/dea-drug-schedule-implications-for-pharmacists-2663824
https://ballotpedia.org/Insurance_Commissioner_(state_executive_office)
https://landing.athenahealth.com/g/meaningfuluse?cmp=43760&utm_source=google&utm_medium=cpc&utm_term=meaningful%20use&utm_type=e&KCID=_k_EAIaIQobChMItsjevqDF5wIVGqSzCh1wtgsbEAAYAiAAEgIELvD_BwE_k_&utm_salesforce=701G0000000WxIpIAK&gclid=EAIaIQobChMItsjevqDF5wIVGqSzCh1wtgsbEAAYAiAAEgIELvD_BwE
https://www.acponline.org/practice-resources/business-resources/payment/delivery-and-payment-models/patient-centered-medical-home/understanding-the-patient-centered-medical-home/what-is-the-patient-centered-medical-home

Amy Brewington

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About author
With 20 years experience in the healthcare industry, my passion is to use my experience and knowledge to help independent providers succeed. My goal is to help them overcome any negative effects from the healthcare reforms and regulations while keeping values and vision to better the health of communities and families. I have 17 years experience in medical billing and coding for multi-specialty groups, 12 years of management experience, and 7 years in the C-suite. Will graduate with a Bachelor's in Business Administration in December 2020. Building a brand in healthcare consulting with a successful track record. I always look for opportunities of growth, wisdom, and knowledge so I can use my skill sets to improve lives.
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