Part 1: The Hidden Risks MCOs Face with Medicaid Disenrollments
In today’s Medicaid environment, MCOs face increasing pressure to ensure continuous coverage for all beneficiaries while maintaining profitability. The recent expiration of pandemic-era protections and the start of the Medicaid "unwinding" period have made it even more challenging to provide uninterrupted coverage. A primary concern is the rising risk of wrongful disenrollments, which can result in significant gaps in care and coverage for beneficiaries.
The Complex Medicaid Landscape
Navigating Medicaid systems is complicated. These systems are often managed by state agencies and third-party contractors, which increases the likelihood of errors. State-provided data, which MCOs rely on to track eligibility, can be inaccurate or incomplete, leading to wrongful disenrollments. As MCOs focus on maintaining profitability and positive health outcomes, overlooking these data errors can have severe consequences for both beneficiaries and the organization.
Hidden Risks MCOs May Be Overlooking
While it’s easy to focus on the most obvious risks, there are several critical factors that MCOs may overlook, amplifying the challenges surrounding wrongful disenrollments:
Inaccuracies in State Data: Medicaid eligibility systems are highly complex and prone to errors. These inaccuracies can lead to improper disenrollments, leaving beneficiaries without necessary health coverage. For MCOs, these errors not only disrupt care but also pose financial risks.
Operational and System Fragmentation: Medicaid eligibility systems are fragmented, varying from state to state. Many states rely on third-party contractors to manage these systems, leading to inconsistencies and data errors. These system errors increase the chance that beneficiaries will be wrongly disenrolled, leading to significant disruptions.
Financial Repercussions: Errors in disenrollment data come with substantial financial consequences. MCOs risk losing members to competitors, which disrupts retention strategies and leads to decreased revenue. Further financial losses can come from the additional costs involved in re-enrollment efforts and administrative processes to correct errors.
Get Insights in Under 3 Minutes
In the video below, Agilian CEO Jamey Harvey provides an in-depth look at why these disenrollments are occurring. His insights can help organizations better understand the hidden risks and navigate the complexities of eligibility verification.
Final Thoughts
In the face of these challenges, MCOs need to rethink their approach to eligibility verification and data management. Without addressing these hidden risks, the negative impact on both health outcomes for beneficiaries and financial outcomes for the organization can be severe. Agilian is here to help MCOs navigate these complexities, ensuring that coverage remains uninterrupted and that the financial health of the organization is safeguarded. Let us help you recover tens of millions in revenue!