Maximizing Education Related Medicaid Claims for Major School District
Solix Case Study
Situation
One of the largest school districts in the country needed a solution to increase federal revenue recovery, and to identify and implement operational efficiencies and compliance enhancements for Medicaid claims processing for special education services. The district required the chosen vendor to have highly trained, experienced and supportive staff, and state-of-the-art, web-based automated solutions for case management, Medicaid billing, and policy and legislative consulting.
Objectives
- Increase the total amount of federal reimbursement.
- Maintain and track federal recovery in a compliant and auditable manner.
- Implement continuous improvement processes.
- Advise District staff on new policy and regulatory requirements.
Challenges
- Achieving the same or higher federal recoveries with lower student enrollment and increased regulatory restrictions.
- Securing new Medicaid recovery revenue stream while minimizing risk.
Solution
- Performed all services necessary to prepare, process, and obtain reimbursement from the State Medicaid agency.
- Audited a random sample of service records to verify that claim data accurately reflected the services delivered with documentation that is federally compliant.
- Identified potentially eligible students not enrolled in Medicaid by utilizing sophisticated matching algorithms.
- Reviewed and analyzed Medicaid cost pool data to ensure compliance and that all claimable costs were included.
- Integrated data from the school district information systems to track students, providers, and service delivery.
- Provided a sophisticated Business Intelligence drill-down reporting and analysis tool.
- Created service detail and rejected claim reports, and with IEP data, identified unreported services.
- Provided training on Medicaid and other claims processing programs.
- Conducted annual cost reconciliation and rate setting.
Results
- Maintained the same base program level of federal recoveries despite declining enrollment and increased regulatory restrictions.
- Obtained 9% in additional revenue streams by implementing enhanced Medicaid eligibility matching algorithms.
- Consistently achieved all service level objectives.