Tennessee allows Hospital Presumptive Eligibility

Gregg Phillips

Effective July 1, 2016, all Tennessee hospitals can immediately determine eligibility for people likely eligible for ongoing TennCare Medicaid. 

The Hospital Presumptive Eligibility program was created by the Affordable Care Act to improve access to hospital services and speed payments to hospitals for those services. 

Hospitals across America are using AutoGov's HPE software, CaseVue, to provide real-time decision support for hospital admissions personnel. 

The attached document provides comprehensive information on the Tennessee HPE program. 

Please call us today at 512-439-2900 for advice, workflow and best practices for implementing HPE on your hospital. 

AutoGov's Income Verification

Solara Cochran

It's the government's responsibility to stop fraud, waste, and abuse.

Without oversight, the door to falsifying income information on a government enrollment application is thrown wide open. An applicant can easily claim a tiny salary just to ensure approval into the government funded program to which they are applying. Approval of unqualified applicants is a serious waste of taxpayer resources. Cancellation of benefits will take months; meanwhile the falsely approved applicant receives thousands of dollars in benefits, defrauding the government and without fear of repercussion. Verification of an applicant's income is critical, and the time to secure the right verification solution tool is now.

The world of quality control and oversight must be expanded at the same rate as the expansion of our government-funded entitlement programs.

AutoGov products provide the best validation and verification services and all at a fair price to ensure the return on investment is high. Our software fuses information to verify identity, residency, citizenship, income and all types of assets are done and on your device in a second.

AVS Projects Robust Return on Investment Saves a State Millions

Solara Cochran

In August 2013, AutoGov began processing Asset Verification Service (AVS) requests for one of our very innovative and aggressive state government clients. After a successful implementation, the entire team was eager to hit the ground running. We were excited and astonished by the swift return on investment: within the first two hours of operation, the uncovered assets found by our solution paid for the entire program in cost savings.

To gain a greater insight into the meaning of this discovery, we must first understand the costs associated with leaving these assets unfound. Using the net present value of $76,000 as the annual cost of a normal long term care (LTC) Medicaid case, use of the AutoGov AVS solution found a great deal more than previous manual verification programs. In fact, the AVS requests produced over one million dollars in previously unknown depository assets, and the solution took, on average, less than 6 days to uncover well over one hundred submitted cases that exceeded the allowable state threshold for Medicaid.

Congress passed Section 1940 of the Social Security Act. This amendment requires states to implement an electronic Asset Verification System (AVS) for the aged, blind and disabled Medicaid population. AutoGov is on the forefront of innovation for integrated eligibility and program integrity, and our AVS project is one of only two fully implemented solutions in the country.

Until now, Medicaid applicants were only required to volunteer their banking information. As an individual, they could simply choose not to disclose a checking, savings, or certificate of deposit account. Medicaid case workers had no way to verify that applicants were fully disclosing all assets. It's a new day, and that is no longer true. With the help of AutoGov and our data partners, Medicaid caseworkers can be sure they are approving the right individuals.

AutoGov continues to uncover waste, fraud, and abuse for state and federal entitlement programs. For a quick and easy AVS implementation with very little upfront cost, contact Solara Cochran at (512) 439-2900 or email solara.cochran@autogov.com.

Where does Medicaid expansion stand today?

Solara Cochran

What are the states going to do?

 The Affordable Care Act will significantly expand both eligibility for and federal funding of Medicaid beginning on January 1, 2014. Under the law as written, all U.S. citizens and legal residents with income up to 133% of the poverty line would qualify for coverage. However, the United States Supreme Court ruled that states do not have to agree to this expansion in order to continue to receive existing levels of Medicaid funding.  Many states have chosen to continue with their current funding levels and Medicaid eligibility standards. 

 Some states such as New Mexico are taking a more progressive approach, asking their Medicaid recipients to pay co-pays for some treatments.  Co-pays will be required for services such as ER visits for routine medical care or using a brand-name drug over a generic.  One of the main goals of the revamped program is to better coordinate the care provided to recipients to improve their health or keep medical conditions from worsening and becoming more costly to treat.  Empowering people to take responsibility for some of their own healthcare costs will likely save millions of dollars for New Mexico.

 The State of Missouri has opted out of the Affordable Care Act Medicaid expansion.  Missouri still plans on reforming Medicaid.  There are now three legislative committees set up to study Medicaid reform.  Missouri law makers want to try and solve some of the problems the Medicaid program faces.  “In my old, country way of looking at things, I’d like to fix the bucket,” said Missouri Senator Jay Wasson. “I’d like to stop the leak before I put more water in it. I wouldn’t put more water in a bucket that already leaks.”  Missouri's leaders seem to want Medicaid recipients to have some skin in the game.  Ideas like incentives for preventative care and co-pays are being seriously considered. 

 Today, Medicaid provides more questions than answers.  Regardless of the outcome, change is on the horizon.  One silver lining in all of the upheaval is technology continues to play an even larger role in finding solutions.  Now organizations like AutoGov can help states, healthcare providers, and the public make decisions based on real-time information.  "Big Data" is alive and well in healthcare.  It is impacting all of us each and every day.

CaseVue Best Practices

Solara Cochran

Successful "real world" examples from our Long-Term Care Customers

Healthcare organizations hire AutoGov to help improve in their admission processes. We can help them by providing a decision assistance tool that will predict the probability of a Medicaid approval in an extremely successful and timely format. Because of our software, AutoGov clients save millions of dollars in write-offs annually.

Customer examples:

One client story begins with a resident referral coming in from the hospital. The Business Office Manager (BOM) utilizes CaseVue with nearly every potential admission. The BOM immediately runs a CaseVue score with the information provided from her referral source. Depending on the admission process (including the CaseVue risk score), that referral can be accepted or denied inside of their policy-based 15-minute time frame. The patient's CaseVue score was helpful in determining that the potential resident would need to address just a few assets before the state would grant an approval. The CaseVue risk score was 56%. Standing in the way of approval, CaseVue uncovered some property in a completely different state. The resident would not qualify for Medicaid without selling the property and beginning a spend-down plan. The family didn't realize their mother owned any property, let alone in another state. Without CaseVue, the state would have denied the residents Medicaid application. In this state, a denial usually takes about 6 months. CaseVue saved everyone involved in the case time and money!!

CaseVue is also helpful in detecting potential fraud. A resident referral was sent to a Long-Term Care Nursing Home by a community resource. The potential resident admitted to being Medicaid Pending and as part of their admission process, the facility administrator ran a CaseVue score. CaseVue returned a score of 0% but verified the Social Security Number to be that of an actual person, one who was deceased. The nursing home was able to avoid potential losses in the hundreds of thousands. Admission was denied due to fraud.

CaseVue, helping real-people make real-world admission decisions!

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