MASH knowledge of program implications makes a difference in hospital's revenue.

DropcapSouthwestern state recently changed utilization review (UR) vendors — the company administering state Medicaid. With that in mind, a MASH Operations Manager's knowledge and experience helped our customer hospital recognize the reimbursement it might be missing.

The Background

MASH has served this 204-bed, not-for-profit, religious teaching hospital since 2000. The hospital utilizes MASH services for primary placements and a second national eligibility vendor for emergency department and ED admit accounts.

The state replaced its longtime UR vendor with another whose medical directors are currently denying many Medicaid claims.

MASH efforts have resulted in over $35 million in reimbursements to this facility since 2000.

The Challenge

Based on her in-depth training and experience, the MASH Operations Manager discovered that Vendor B's employees were shortcutting to the easy-to-file federal program, "Non-US Citizens Needing Emergency Services (1011)," for uninsured patients, rather than filing more time-consuming applications for the state Medicaid program — for which the patients also qualified. She warned the hospital that its Medicaid funding would be much less than in previous years. Some reimbursements would be made under the federal program, but in addition to lower Medicaid payments, the hospital's DSH reimbursement would decline as a result of Vendor B's employees' lack of program knowledge.

The Response

The MASH manager also alerted the hospital administration that changes in the state's Medicaid utilization review company were likely to result in lower hospital reimbursements — an unhappy event for which the hospital should be prepared.

The Results

Because of its confidence in MASH's training and program proficiency, the hospital asked the MASH manager to meet with state officials to explain how the coming shortfall would adversely affect the hospital and other providers statewide.