As Medicaid Funding Changes Approach, Health Plans Must Prepare for Unintended Consequences

A recent analysis from the Robert Wood Johnson Foundation forecasts a significant $80 billion reduction in provider revenue by 2026 if states modify Medicaid expansion programs. This concerning projection, reported by Fierce Healthcare, indicates substantial financial challenges ahead for healthcare providers nationwide. Link and citation here

For health plans, these changes create new risk landscapes that require enhanced vigilance and proactive approaches.

Understanding Provider Response to Financial Pressure

History has shown that when healthcare organizations face revenue constraints, they may respond with billing practices that require closer scrutiny. These responses aren't limited to intentional bad actors but can emerge as systemic adaptations to financial strain.

We've observed various patterns:

• Increased complexity in visit and procedure coding

• Documentation that doesn't align with services delivered

• Strategic claim submission approaches to optimize reimbursement

• Disaggregation of bundled services

• Duplicate claim submissions

These challenges require health plans to implement more sophisticated oversight mechanisms while maintaining positive provider relationships.

Balancing Payment Integrity with Provider Partnerships

At Nokomis Health, we've developed approaches that identify potential issues before claims are paid while preserving collaborative provider relationships. Our ClaimWise™ technology conducts comprehensive line-by-line reviews across all claims—not just sampling high-dollar cases.

Our comprehensive review encompasses:

• Evaluation & Management (E&M) services

• Diagnostic services including radiology and laboratory

• All levels of hospital care

• Ancillary services including those with lower individual values

This approach delivers impressive results: 99.53% realization rate with appeal rates below 2% and overturn rates under 0.5%. These metrics demonstrate our ability to protect appropriate spending without undermining crucial provider partnerships.

Beyond Detection: Prevention Through Education

Our philosophy extends beyond identifying billing discrepancies. We recognize that many providers navigate increasingly complex billing guidelines and genuinely aim for compliance.

Nokomis Health offers targeted educational resources for providers as an integral part of our services. These range from clarification discussions on specific claims to structured sessions addressing recurring patterns. This collaborative approach:

• Minimizes administrative friction

• Enhances long-term billing accuracy

• Strengthens health plan-provider relationships

• Prevents future compliance issues proactively

Preparing for the Road Ahead

As Medicaid funding changes take effect, billing behaviors will inevitably evolve. Health plans without robust oversight systems may experience significant unnecessary expenditures.

At Nokomis Health, we believe payment accuracy serves the larger purpose of protecting healthcare system integrity. Our approach helps health plans implement early, precise, and transparent claim review processes.

Interested in learning how our pre-payment review methodology and provider education programs can strengthen your organization's payment integrity?

Visit nokomishealth.com or connect with me here on LinkedIn.

Author

Chris Wilson

EVP Sales

April 15, 2025