As of August 2024, over 72 million people are enrolled in Medicaid. The program is a critical piece of the US Healthcare system, giving coverage to people and families who struggle to be insured. Additionally, Medicaid covers long-term health issues that private entities may reject.
However, the Medicaid system is fraught with challenges. For the best use of the services, Medicaid case management is growing in popularity to meet the rising needs. In Medicaid case management, a professional case manager works with Medicaid enrollees to identify goals, develop a care plan, and make the most of the opportunities available within their insurance.
For Medicaid case managers to make the best use of their time, they need a system that connects all the relevant parties for one of their clients. They cannot accurately plan for the best outcome without being able to talk to different doctors and providers, gain access to case notes, and see a complete picture of each person's needs. These problems are solved with Medicaid case management software, creating a hub for every stakeholder to communicate.
In this article, we'll dive into the challenges of Medicaid case management and how software can improve Medicaid compliance and help caseworkers deliver better care.
Understanding the Challenges in Medicaid Case Management
Medicaid case managers come across many challenges in their daily work. If they don't have all the information in front of them, they cannot make informed decisions about the services their clients need. Additionally, nearly 17% of in-network claims across HealthCare.gov insurers were denied in 2021, making it difficult for case managers to do their job.
Additional challenges include:
- Complex eligibility requirements: The Medicaid eligibility requirements are lengthy and vary by state. Individuals covered in one state may not be covered in another, making it difficult for people to understand how to use their insurance.
- Frequent updates: Due to the recent COVID-19 pandemic, many people received Medicaid coverage that they would not have otherwise received. These pandemic protections have slowly been cut back, and it can be confusing to figure out if a client is still covered or not.
- Rigorous service authorizations: All case workers must use a service authorization request form to substantiate a medical necessity. If these are not filled out correctly, it can lead to a denial.
- Excessive documentation: Case workers must heavily document all services, especially for targeted case management, to ensure Medicaid claims are approved. The amount of time spent on data entry and paperwork varies greatly depending on the state, anywhere from 15% in New York to 65% in Minnesota.
- Medicaid billing errors: A case worker may not have the most up-to-date information for a client, leading to billing errors such as delayed payments, claim denials, Medicaid reimbursements, or audits and penalties.
- Differing standards of quality assurance systems: Since Medicaid is such an extensive system, there are issues with controlling the quality each person receives. Medicaid includes a disproportionate number of vulnerable individuals from rural locations, making it harder to give them the same care as those located in urban areas.
Benefits of Implementing Medicaid Case Management Software
Overcome these challenges in Medicaid case management with case management software like PlanStreet. This tool creates a single spot for communication between different providers, so case managers always have the most up-to-date information. Here are some more benefits that can help case managers streamline their day and improve patient outcomes.
- More accurate Medicaid claims processing and billing: Data aggregation in software becomes automated through client intake forms, Medicaid claims data, bulk claims, and secure online invoicing. This means that the data included in a SAR is more accurate, leading to fewer denied claims.
- Refined workflows for case managers and providers: Customizable dashboards allow each caretaker to refine the software to work for their exact needs. Scheduling tools also help case managers manage time, schedules, and payroll expenses through animation.
- Better client outcomes: Create personalized care plans in the software based on real-time data. Case managers can use analytics tools to see which services have worked best in the past, helping them make the best decision at the moment.
- Improved cost savings: Adding automated processes from case management software can reduce the expense of a claims journey by up to 30%.
- Simplified compliance: Robust organization and security features in software (like a claim status tracker or waiver organization tools) like PlanStreet can help your team match state, local, and federal regulations, ensuring that your team remains compliant.
How to Choose the Right Medicaid Case Management Software
Step 1. Define Your Goals and Requirements
Schedule a meeting with your team and outline the main challenges and pain points with the systems that you're currently using. What are the changes that you hope to make? What metrics will you follow to ensure that the outcomes are met? Write all of this down so that you have it when looking at different software options.
Additionally, take an inventory of your current workflows and protocols. What are you spending money excessively on right now? Create a software budget based on the current methods that could be replaced. 20% of businesses report their paper consumption is increasing, which increases costs. Data-driven software cuts these overhead costs while offering more security.
Step 2. Consider Scalability and Customization
Healthcare providers through Medicaid want to increase their operations to help more people and increase profits. Look for Medicaid-specific features that allow your team to scale operations while offering enough customization so that each person can use the software in the way that's best for their workflows.
Additionally, consider how related stakeholders may want to use the software. Part of a Medicare case manager's job is managing comprehensive care, so consider the needs of different providers as well.
Step 3. Check How It Operates With Your Current Systems
70% of digital transformation projects fail to reach their planned goals. While Medicaid case management software can be a lifesaver, you cannot completely replace what you have. Do a software inventory: keep what your team likes and replace the rest, double-checking that the new software works with the systems you intend to keep. Additionally, plan for a slow adoption process, and be sure to educate your team on best practices.
Step 4. Verify Compliance With Medicaid and HIPAA Standards
Case management software must be HIPAA-compliant and should also offer standards to remain compliant with Medicaid. Check the website for a page that outlines the software's HIPAA compliance and the tools offered to help your organization remain compliant as well. There may be different rules for Medicaid compliance. If the website doesn't seem clear, schedule a call with their team to ask your questions.
Step 5. Check for User-Friendly Dashboards and Reporting Tools
UX (user experience) design should be at the forefront of any software. After all, case managers aren't experts! The dashboards, where people can find information and use the software and reporting tools to check data should be intuitive. Ask for a demo so that the team can show you all the tools and you can see firsthand how easy they are to use.
Must-Have Features in Medicaid Case Management Software
While shopping for software, you also need to consider the best features for Medicaid case management specifically. Software such as PlanStreet can be customized based on the needs of the service area, so the specific type of case manager can create a solution that fits with their everyday work. Features to look for include:
- Real-time eligibility verification to speed up when patients can receive care.
- Automated billing and claims management to minimize administrative time.
- Integration with Medicaid Management Information Systems (MMIS) to meet principal objectives.
- Compliance tracking and reporting to avoid legal issues.
- Online payment processing to speed up billing for Medicaid.
- Activity tracking to see a client's progress from start to finish.
- Scheduling and time tracking tools to track deadlines, book meetings, and organize client care plans.
- A patient self-service portal so that clients can easily access critical information for their health.
Level up Your Medicaid Case Management Software With Plan Street
Medicaid case management is a critical process that ensures individuals receive the best care possible with their health plan. Medicaid case management software gives social workers and case managers the tools they need to create robust care plans, speed up Medicare claims, and communicate with all relevant stakeholders to ensure their clients get the best care they deserve.
Improve your Medicaid case management with PlanStreet. Our flexible health and patient management services case management software works within your team's unique structure and abilities. Your team doesn't have to change to meet the software; rather, our software can be customized to work with your preferred methods.
PlanStreet offers all of the must-have features listed above and more. Let us show you how PlanStreet can improve your workflows, and schedule a demo with our team today.