More than 75 million people access comprehensive and cost-effective care through Medicaid, including low-income families, older adults, and individuals with disabilities or chronic conditions.
Given the program’s importance in addressing the health needs of vulnerable populations, optimizing the experiences of Medicaid members and providers is critical. How they interact with the program can impact many outcomes, from member access and care utilization to provider participation and compliance.
As states move from integrated Medicaid Management Information Systems (MMIS) to modular Medicaid Enterprise Services (MES) frameworks, opportunities to improve the experience lifecycle are found in the MES components that most directly touch members and providers. With this focus on experience, state Medicaid leaders can align their MES solutions to support the overall program mission and improve the wellness of members.
For states looking to undertake this transition from traditional MMIS to MES modernization, below are four considerations to guide this journey.
1) Analyze and prioritize.
As state Medicaid programs evolve and implementation risks arise, it’s essential to prioritize areas where change can yield the greatest potential benefit. Think about the areas that can optimize provider empowerment and self-service, reduce hassle factors, and enhance the member program lifecycle experience. Target areas that can improve quality and increase program agility. And identify areas, functions, and capabilities that could become standalone modules with integrated capabilities.
Taking a combined modernization and modular approach can mitigate risk and unintended negative impacts on your program. For example, while it may be too difficult to replace the claims component, modernizing the financial functions can improve flexibility. Modernization efforts that incorporate self-service capabilities, improve communication flow, and increase the efficiency of transactional processing can empower providers and reduce their obstacles.
2) Separate fiscal agent and program operations.
As you prioritize modernization, consider separating traditional Medicaid operations (or “fiscal agent” functions) from the technology solutions that support your program. After all, the vendor that brings the best technology module may not have the experience or expertise to offer the best operations and engagement solution to support your member and provider interactions. Instead, choose a vendor that shares your mindset of improving member and provider experience. Together, you can apply a “program operations” lens that focuses on customer service, prior authorizations, claims and encounter adjudication support, appeals, provider services, and outreach.
Beyond these provider and member touch points, consider including support for program policies, provider financial functions, reporting, analysis, managed care organization support, enterprise data standardization and strategy, and other services key to your program’s mission. They represent opportunities to improve communication, workflow, quality, and efficiency, aligned with your state’s Medicaid goals for a comprehensive “end-to-end” program view.
3) Narrow your focus on provider and member experience.
Next, consider carving out the provider services functions as standalone enrollment and self-service portal modules. Modernizing this capability can greatly enhance the provider experience by streamlining their processes and focusing on their program interactions. It offers providers empowerment and efficiency through self-service eligibility verification, claims submission, adjustment and status verification, prior authorization submission, remittance, and status reporting, as well as access to fee schedules, communications capabilities, and integrated enrollment and credentialing processes. Simply put, it makes it easier for providers to be part of your Medicaid program.
4) But don’t forget the data.
With modernization and modularization, your enterprise data strategy becomes even more important. Every modernization project must ensure accurate use, integration, and exchange of data across modules and proper data management by and between vendors. Conversion and transformation of legacy data into repositories of new modules can be both complex and risky. Having a defined enterprise data strategy to guide your modernization effort helps mitigate possible delays.
As technology advances and data science techniques—including artificial intelligence and machine learning—mature, use them to illuminate Medicaid program trends, data correlations, and potential fraud that may have been previously unknown. These insights can support program effectiveness, provider adequacy, outcomes analysis, and program integrity—all areas that impact member and provider experience.
Modernization in support of the mission
Medicaid programs are complex and critical. Implementing new MES modules and modernizing program capabilities can be a major undertaking that may feel perilous. Leveraging modernization techniques, technologies, and modular solutions can streamline and optimize critical functions that enhance the program life-cycle experience for providers and members.
Even with a well-crafted modernization roadmap, some challenges are inevitable, and the support of a strategic partner is invaluable. The right partner, equipped with deep domain knowledge, an understanding of the program’s mission criticality, and a strong focus on member and provider experiences, can support states with their modernization vision, planning, data strategy and integration, risk mitigation, and quality assurance.
Through meticulous oversight and expert guidance, states can achieve success in their modularity and modernization goals, improve program efficiency and effectiveness, and ultimately support Medicaid’s mission.
About Donna Migoni
Donna Migoni brings over 30 years of experience in steering product vision, capabilities, service delivery, and technology initiatives within government health and human services programs. Currently leading the Medicaid Enterprise Services division (MES) at Maximus, Donna is responsible for enhancing service delivery and optimizing user experiences for members and providers.
Before joining Maximus, Donna had a distinguished career holding executive, leadership, delivery, and architecture roles at EDS, Accenture, and Conduent, where she oversaw Conduent’s Government Health Services division.
