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What Changing Payer Mix Means for Hospitals and Medical Facilities

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An uptick in unemployment and Medicaid will cause a decrease in employer-sponsored insurance plans. So, what does the influx of patients changing coverage mean for hospitals and medical facilities?

July 27, 2020


(Updated October 16, 2020)

With the onset of COVID-19, the U.S. saw unemployment rates that surpassed that of the 2008 recession (14.7% in April 2020).1  Fortunately, that number is starting to creep back down, but unemployment still remains double of what it was prior to the pandemic. The overall increase in unemployment also means an increase in Medicaid enrollment. It also means that people are losing and gaining employment, which means changes to healthcare coverage.

A simultaneous uptick in unemployment and Medicaid will also cause a decrease in employer-sponsored insurance plans. Individuals and families living under 400% of the national poverty level can qualify for subsidized coverage through the ACA marketplace.2 Although Medicaid expansions and access to subsidized insurance plans make it unlikely that the self-insured population will mirror that of the Great Recession, we are still likely to see a bigger increase in Medicaid and Marketplace plans.

So, what does this changing payer mix mean for hospitals and medical facilities? 

Assist with Medicaid enrollment

First, helping eligible patients enroll for Medicaid is especially critical because retroactive coverage may date back three months before the application date filed. Meaning for you to take full advantage of the Retroactive Medicaid window, the patient needs to apply within three months of when they become eligible.

Furthermore, quicker enrollment will mean that Medicaid pays you sooner, which is also critical if your hospital is seeing a massive decline in revenue.

When you’re not aware of changes to someone’s insurance or eligibility status, money is left on the table by not billing the appropriate payer. The issue is compounded as people become eligible for retroactive coverage through Medicaid. It’s hard to keep track of uninsured patients that transitioned to Medicaid after you treated them, and each occurrence leaves hundreds, if not thousands, of dollars on the table.

Identify ALL billable encounters for Medicaid

Second, hospitals and medical facilities should be vigilant and use a systematic approach in identifying billable encounters for Medicaid. Since you can bill Retroactive Medicaid for up to three months prior to the application date, your previously rendered services could now be covered, even if the patient wasn't enrolled at the time.

Many healthcare organizations are losing money or struggling with already narrow margins so searching for billing opportunities from Retroactive Medicaid eligibility can help infuse some cash into your bottom line.

Empower staff with insurance verification and insurance discovery 

Third, anticipate a surge of insurance changes as unemployment continues to rise, causing patients to lose employer-sponsored health plans. Some will enroll in marketplace plans, some will become eligible for Medicaid, and some will become uninsured. These increased changes compounded with the existing problem of tracking ever-changing patient insurance puts additional strain on registration staff. The billing office is also facing a downstream impact with claims billed to termed insurance plans or missed coverage.

To alleviate burnout and ensure that you aren't missing billing opportunities, insurance verification and insurance discovery efforts should be in place.


Learn more

Ready to infuse your organization with revenue and make sure you aren’t missing any billing opportunities? Check out our new risk-free tool − BOOST: Backlog Search™ − giving you and your staff a chance to prevent missed billing opportunities.


Written by Rachel Bowles - BOOST Product Manager

Rachel Bowles - BOOST Product Manager

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