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How Automation Can Support the Upcoming Medicaid Redetermination

By: Chris Lamonica
Published: February 24, 2022

Medicaid remains a critical support system for those who rely on it for their medical care. Its importance has only grown as the United States, like other nations, battles through a pandemic that has changed the overall landscape of life, health, and the livelihood of its citizens over the past two years. 

Similarly, the Children’s Health Insurance Program (CHIP) is another related program that helps provide health insurance for children of whom would otherwise be uninsured. Both of these state and local administered programs have been integral in supporting low-to-moderate income families through the pandemic. 

Unfortunately, current volume increases due the pandemic aside, there is a looming logistical lift incoming. The process of redetermination at the end of the Public Health Emergency declaration will require state and local agencies to quickly and accurately process millions of documents to serve over 83 million constituents and meet deadlines. 

Redetermination involves confirming the eligibility of current Medicaid members by collecting various documents to determine their current financial status. This process is lengthy, complex, and typically requires extensive resources—so state and local organizations are now considering automation solutions that will help them meet the task. 

How The Pandemic Broadened Medicaid

The declaration of a Public Health Emergency (PHE) by the Secretary of the Department of Health and Human Services broadened the functionality of Medicaid to provide more support to citizens in each state.

Firstly, the Families First Coronavirus Response Act (FFCRA) temporarily increased federal Medicaid payments to provide virtually all beneficiaries with uninterrupted enrollment for the duration of the public health emergency. 

Second, under special federal public health emergency powers, many states actually broadened eligibility for Medicaid, especially for people with serious disabilities who need long-term care. 

The combination of these two elements led to Medicaid enrollment growing sharply, by 18.7% in the median state—with over 83 million individuals enrolled in both Medicaid and CHIP as recent as July 2021. 

While broadening this essential social service has benefited millions of individuals, it’s also set the stage for what is sure to be an operational challenge in the coming months. 

The Looming Redetermination Processing Challenge

State and local departments are already struggling to allocate enough resources to stay ahead of the uptick in medicaid enrollments, especially when their own employees are working remotely due to social distancing guidelines. 

This has led to backlogs in both eligibility & enrollment processing and claims processing. In fact, one southern state found themselves with a backlog of over 2 million claims during early 2021 (that they then leveraged the Hyperscience Platform to process automatically and work through in the summer of that same year). 

This is only the tip of the iceberg: At the time of writing, the PHE (and the eligibility and funding increases it provides) is due to end on April 16th. 

If it is not extended again, when that expiration occurs, all states will have to perform redetermination of current Medicaid members to ensure their eligibility—a monumental task involving the processing of documents of over 83 million individuals. In practice, this means that all 50 states and 5 U.S territories, with their own specific eligibility requirements and diverse operations and systems of record, will have to confirm the current status of all Medicaid members—a task that is further compounded by some states requiring this redetermination to occur within 90 days. 

A perfect storm is brewing in state and local offices across the country.

Some organizations have already started expediting their digitization efforts with the hope of being prepared when the end of the PHE comes. With these efforts, and our experience with state and local agencies in mind, one thing has become abundantly clear: State and local agencies that leverage automation in an effective and efficient manner will best support their constituents through redetermination.  

How State & Local Agencies Can Leverage Document Automation

The complexity of state and local agency operations cannot be underestimated when it comes to finding and implementing an automation solution that will improve efficiency. Legacy tools that lack flexibility, require a lengthy deployment, and struggle to integrate with your existing systems risk adding complexity at a time when simplicity in your workflow is integral. 

When searching for an automation solution, three qualities should be considered necessary: 

  • Flexibility: The automation solution you select should be able to automatically classify, extract, and enrich data from any document type, regardless of structure (from tax forms to state identifications), quality (including low quality images and scans), and text type (handwritten or machine-printed). Solutions that struggle with edge cases can create unnecessary interruptions in your daily workflow—or worse, insurmountable bottlenecks when volume is at its highest.

> Only the Hyperscience Platform has the flexibility required to allow agencies to inject diverse, complex document formats into the process and reliably extract, verify, confirm, or enrich that data to be utilized downstream in your eligibility and enrollment workflow. 

  • Accuracy: The automation solution you select should have a high degree of accuracy, enabling your employees to feel confident that the data they’re acting on downstream is correct. 

> The Hyperscience Platform enables human and machine collaboration to ensure accurate, complete data extraction with minimal manual intervention. It will classify and extract data automatically against your set accuracy rate. At times when it feels unsure it can meet that threshold, it will bring a human-in-the-loop to confirm its understanding of the content. In doing so, it uses Machine Learning (ML) to learn from those instances and improves automation rates over time as it better interprets the type of data it’s extracting. 

  • Modularity: The automation solution you select should tailor to your specific workflow, current systems, and processes—including a fast, easy, and secure initial deployment. When changes are required due to regulatory changes, it should adapt to those changes with limited external reliance and minimal downtime. 

> The Hyperscience Platform integrates with your current systems, including RPA solutions for ingestion and downstream systems for project management. This includes our ability to transform data into actionable JSON outputs. With the flexibility enabled by our robust, modular automation platform, you can create a tailor-made solution for your specific organization—and change it at will when regulatory or operational changes dictate. 

The key to state and local agencies successfully leveraging automation during this incoming flurry of redetermination is to ensure that the solution they select is intelligent, capable, and highly adaptable. 

Interested in seeing the Hyperscience Platform in action? Get a demo today!