As of May 2023, several states have initiated Medicaid roll purges as part of their ongoing efforts to maintain program integrity and eligibility compliance. The following states are notable examples: Alabama, Arkansas, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, and Massachusetts.

Each state has its own set of criteria for eligibility. Generally speaking, states are purging their rolls based on an automated system that compares Medicaid enrollees against state and federal databases. This process usually begins with a review of the enrollee’s name and date of birth. Other criteria were also considered:

• Some states implemented a Medicaid roll purge based on a combination of factors. Eligibility reviews were conducted to verify income levels, household composition, and residency status. Recipients were required to submit updated documentation to demonstrate continued eligibility. Failure to comply resulted in removal from the Medicaid program.
• Others undertook a Medicaid roll purge, primarily focusing on residency and citizenship verification. Recipients were required to provide updated documentation, including proof of residency and citizenship, within a specified timeframe. Non-compliance led to the removal of individuals from the Medicaid program.

• Lastly, some states implemented a Medicaid roll purge targeting income verification. Recipients were required to submit updated income information and supporting documentation. Failure to comply resulted in eligibility reassessment and potential removal from the program.

Implications for Medical Billing:

The impact of purging Medicaid rolls will vary from state to state. However, one thing is sure: medical billing will be affected. In some states, providers will no longer be able to bill Medicaid for services rendered to those removed from the rolls. In other states, providers will be able to bill Medicaid but will not be reimbursed for services rendered.  The following points highlight the potential consequences:

Patient Disruptions:

• Medicaid roll purges may lead to disruptions in healthcare coverage for individuals who are incorrectly removed from the program due to administrative errors or difficulties in meeting the verification requirements. Such disruptions can impact patients’ access to essential healthcare services and increase their financial burden.

Increased Administrative Burden:

• Healthcare providers may experience an increased administrative burden due to Medicaid roll purges. Providers must ensure that patient eligibility is verified and updated regularly to prevent potential billing errors and reimbursement delays. This requires additional resources and time, potentially straining the healthcare system.

Billing Errors and Reimbursement Delays:

• During Medicaid roll purges, billing errors and reimbursement delays can occur as providers adjust to patient eligibility status changes. Therefore, providers must update their billing systems and ensure accurate coding and documentation to avoid claim denials or delays in receiving reimbursement.

Financial Impact:

• The financial impact of Medicaid roll purges on healthcare providers can be significant. Removing patients from the Medicaid program may reduce revenue, mainly for providers serving many Medicaid beneficiaries. As a result, providers may need to explore alternative reimbursement mechanisms or seek additional funding sources to offset potential losses.

Several states have undertaken Medicaid roll purges as part of their efforts to ensure program integrity and eligibility compliance. While these purges aim to enhance the effectiveness of the Medicaid program, they also pose challenges and potential implications for medical billing. Ideally, states will find a way to work together with Medicaid agencies, healthcare providers, and beneficiaries to find a way that verifies eligibility while also keeping healthcare coverage intact. By collaborating and addressing the obstacles of Medicaid roll purges, the people who genuinely need healthcare services will receive the help they deserve.