Out-of-State Medicaid Case Study

Case Study | January 18, 2023

Strategic Vendor Partnership Helps Health System Improve Out-of-State Medicaid Processes and Increase Collections

Out-of-State Medicaid Billing and Enrollment Burden

Of all the types of complex claims, out-of-state Medicaid can be one of the most difficult to manage. It is common for healthcare providers to write these accounts off, not only because they require significant effort and specialized expertise to recover reimbursement, but often they represent a small portion of their overall accounts receivable inventory. Medicaid can be one of the most challenging insurers to bill ¹, as billing requirements vary from state to state and change frequently, and these claims are increasingly hard for providers to identify due to the rise of managed care. Additionally, many states pay out-of-state providers at lower rates than in-state providers and require them to screen and enroll their physicians even if the physician is already enrolled in Medicaid in another state. ²

If a provider doesn’t have the resources in-house to manage these complicated claims, outsourcing out-of-state Medicaid billing and enrollment can be a viable solution. By engaging a trusted revenue cycle vendor who has the expertise, technology, and processes to efficiently resolve out-of-state Medicaid claims, a provider can significantly increase reimbursement and free up in-house resources to focus on other priorities. The right partner can navigate Medicaid requirements in all 50 states, develop a program to accomplish goals and secure payment on as many accounts as possible, as quickly as possible.

The Challenge

An East Coast-based non-profit health organization with a network of hospitals, outpatient services, long-term care facilities and healthcare centers, found that an increase in out of-state Medicaid claims was bogging down its internal staff. They did not have the resources or the processes in place to work them and could not keep up with out-of-state Medicaid enrollments. Many of the system’s physicians, both directly employed with the organization and those who were contracted, were not credentialed in the states their patients lived. They needed a vendor to ensure their physicians were Medicaid-enrolled in these states before reimbursement could occur.

The Solution

The health system chose Elevate Patient Financial Solutions℠ to manage their out-of-state Medicaid billing and enrollment and to build an effective process that would meet the organization’s goals. ElevatePFS analyzed the system’s patient account data, reviewing their past and present inventory, and learned that most of the system’s out-ofstate patient population came from the bordering states.

From there, ElevatePFS researched each state’s requirements and the documents needed for those states. By building strong relationships with the health system’s leadership, ElevatePFS was able to monitor the system’s physicians, learning which needed to be enrolled. By working closely with the client and understanding their needs, ElevatePFS built a customized solution that worked for the client, including rolling out a border state program and physician enrollment program to effectively manage out-of-state Medicaid claims. The programs enabled the client to have processes in place for patients coming from these states and to enroll their physicians proactively and efficiently, which streamlined the reimbursement process.

The Results

By implementing the border state and physician enrollment programs, over the next five years, ElevatePFS was able to increase reimbursement for the health system from a monthly average of $116k to more than $1.5M. By focusing on the right areas and launching customized programs and processes, the number of misassigned claims was dramatically reduced, and the enrollment process was streamlined. This resulted in timely billing and follow up that maximized reimbursements and shortened the health system’s A/R cycle. ElevatePFS ensured this often-neglected portion of the A/R inventory received the attention it deserved. They took the time to credential groups of physicians in each of the states, understanding the different requirements in those states. To date, ElevatePFS has enrolled more than 375 physicians and collected more than $54 million for this health system.

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The Elevated Difference

For more than 20 years, ElevatePFS has offered out-of-state Medicaid enrollment and billing services to hospitals and health systems nationwide. The ElevatePFS full-service solution includes a team of experts with physician and facility enrollment and billing experience in all 50 states.

ElevatePFS does the hard work that is needed to resolve these difficult accounts. They focus resources on areas that will produce the greatest result and build customized programs, leveraging strong internal hospital relationships, and freeing up hospital staff to focus on other priorities. Additionally, as ElevatePFS discovers opportunities for hospital process improvement, they share what they have learned with the client to help them continually improve their internal processes, which translates to more potential efficiency and revenue recovery in the future.


1. “The Complexity of Billing and Paying for Physician Care,” Health Affairs, April 2018, https://www.healthaffairs.org/ doi/10.1377/hlthaff.2017.1325

2. “Medicaid Payment Policy for Out-of-State Hospital Services.” MACPAC, January 2020, https://www.macpac.gov/ publication/medicaid-payment-policy-for-out-of-state-hospital-services/