The front desk at a four-provider pediatric practice has a new morning ritual. At 7:15 the lead opens six payer portals in six browser tabs, plus the state Medicaid portal, and starts down the day's schedule of 110 patients. She gets through about 60 before the first patients arrive. The rest are checked between check-ins, or not at all. This has been the routine since the last week of February, when real-time eligibility through the practice's clearinghouse connection stopped, and while the connection has been partly restored, the payer list is still incomplete.
The AMA released survey results on April 10 that put numbers on this. Of more than 1,400 practices surveyed between March 26 and April 3, 22 percent still could not verify eligibility electronically, 32 percent could not submit claims, 36 percent had claim payments suspended, and 80 percent had lost revenue from unpaid claims. At the same time, the Medicaid unwinding continues: according to KFF's tracker, as of March 12, 2024 at least 18.2 million people had been disenrolled from Medicaid since states resumed eligibility reviews in April 2023, and about 70 percent of those disenrollments were for procedural reasons, meaning paperwork rather than a finding of ineligibility. Put those two facts together and you get the situation in that pediatric office: more patients than ever whose coverage has quietly changed, and fewer tools to find out before the visit.
Key takeaways
- When eligibility is manual you cannot check everyone. Sort the schedule into tiers by dollar and coverage risk, and check Tier 1 the afternoon before.
- Medicaid and marketplace patients are Tier 1 all year during the unwinding, whatever the visit type.
- The MAC portal, Availity, payer portals and the state Medicaid portal all still work. So does asking the patient about renewal letters.
- A patient terminated for procedural reasons usually has a 90-day reconsideration window with retroactive coverage. Hold the claim; do not bill self-pay on day one.
- Sort the returning denials by code: CO-27, CO-22, CO-109 and PR-31 each have a different fix, and most are a rebill to the right payer, not a write-off.
Verify by risk, not by schedule order
When eligibility is manual, you cannot check everyone. Accept it and decide who gets checked first. We sort the schedule into three tiers:
| Tier | Who | Check |
|---|---|---|
| 1: Always verify | Procedures, infusions, imaging, new patients, anyone with Medicaid or a marketplace plan, anyone whose last verified date is more than 60 days old | Payer portal or phone the day before; document the reference number |
| 2: Verify if time allows | Established patients with commercial or Medicare coverage verified within 60 days, routine follow-up visits | Portal check morning of, or card scan and attestation at check-in |
| 3: Card and attestation | Established Medicare patients seen in the last 30 days, nurse visits, low-dollar follow-ups | Front desk confirms card and asks "any changes to your insurance?" with the answer recorded |
Medicaid and marketplace patients are Tier 1 regardless of visit type this year. That is the unwinding talking. A patient who was covered in February can be disenrolled in March for a renewal form that went to an old address, and neither the patient nor the practice will know until the claim comes back CO-27.
Applied to that pediatric practice: of 110 patients on a typical day, about 45 are Medicaid managed care, 6 are new patients and 4 are procedures or in-office tests worth more than $300. That is 55 Tier 1 checks, which at three minutes each is under three hours of portal work. Done the afternoon before by one person, it fits. Done at 7:15 the morning of, across the whole schedule in order, it does not, and the patients who slip are random rather than low-risk.
The tools that still work
Medicare. Your Medicare Administrative Contractor's provider portal returns eligibility, deductible status and Medicare Advantage enrollment. If a Medicare patient has joined an MA plan, the MAC portal shows it, which is the single most useful check for avoiding a claim sent to the wrong payer.
Commercial payers. Most large carriers have their own portals, and many participate in Availity, which consolidates several payers under one login. Set up staff logins now if you have been relying on one shared account; portals lock accounts that log in from multiple places.
Medicaid. Every state has a provider portal or an automated phone line for eligibility, and most show the managed care plan assignment, which matters because the claim goes to the plan, not the state. Check the assignment date; a patient who moved between plans in the unwinding has two payers in one year.
The patient. Ask at scheduling and again at check-in. Patients often know they received a renewal letter and did not return it. A one-question script, "Have you had any letters from Medicaid or your insurance about renewing?", surfaces problems that no portal will.
A secondary clearinghouse. If the practice enrolled with a second clearinghouse in March, its real-time eligibility is usually live for the major payers within days, well before claims enrollment finishes. Ask the vendor which payers respond to a 270 today and move those off the portal list.
When coverage has lapsed
A patient who has lost Medicaid for procedural reasons can often be reinstated. Federal rules require states to allow a 90-day reconsideration period after a procedural termination: the patient submits the missing paperwork, and if still eligible, coverage is restored back to the termination date. For the practice this means two things. First, do not turn the patient away or demand full payment on the spot; explain the reconsideration option, hand them the state's contact information, and see them. Second, hold the claim rather than billing self-pay immediately. If coverage is restored retroactively, the claim goes to Medicaid as if nothing happened. Set a 45-day follow-up on every held claim.
For patients who are genuinely no longer eligible, the conversation is about marketplace coverage, which has a special enrollment period for people losing Medicaid, and about the practice's self-pay policy. Have both on one handout. For a pediatric practice, add CHIP to the handout: a child who no longer qualifies for Medicaid because household income rose often qualifies for CHIP, and the application is the same in most states.
Working the eligibility denials from the outage
Claims submitted during February and March without verified eligibility are now returning. The denial codes to sort by:
- CO-27 (expenses incurred after coverage terminated). Check whether coverage was restored retroactively; if not, identify the current payer through the MAC portal or the state portal and rebill. If there is no coverage, move to patient responsibility with a clear statement.
- CO-22 (coordination of benefits, another payer is primary). Common when a Medicare patient joined an MA plan or a Medicaid patient moved to a managed care plan. Rebill to the correct primary.
- CO-109 (claim not covered by this payer, send to the correct payer). Same handling as CO-22; the remittance often names the correct payer.
- PR-31 (patient cannot be identified as our insured). Usually a subscriber ID or date of birth error, or a plan change. Correct and rebill before assuming the patient has no coverage.
Work these by dollar value and by timely filing risk. A February date of service with a 90-day commercial filing limit is already near the edge; rebill to the correct payer this week and keep the original submission record to support a timely filing appeal if needed. Track the four codes as a share of total denials each week. In a well-run practice, eligibility-related denials normally sit in the low single digits as a share of claims; if yours are above 10 percent this month, the front-end tiering above is where the fix is, not the back-end rebilling.
Mistakes we are seeing
Checking eligibility for the whole schedule and running out of time before the Tier 1 patients. Trusting the card: a card proves the patient had coverage when it was printed. Billing self-pay on the day of a Medicaid lapse without mentioning reconsideration, which loses the patient and the claim. And letting the outage become the permanent excuse: by now most practices can get real-time eligibility back through a restored connection or a secondary clearinghouse, and the manual method should be shrinking week by week, not becoming the new normal.
Questions we hear
How much time should manual verification take?
Two to four minutes per portal check, longer by phone. For a 100-patient day with Tier 1 at about a third of the schedule, that is 60 to 120 minutes of focused work, which is manageable if it is scheduled the afternoon before rather than squeezed into the morning.
Should we collect a deposit from patients whose eligibility we could not verify?
For commercial patients with a known copay, collect the copay as usual. For Medicaid patients, no: most states prohibit charging Medicaid-eligible patients beyond the plan's cost sharing, and a patient in a reconsideration window may turn out to have been eligible all along. Record that eligibility was unverified, see the patient, and hold the claim. Ask your state Medicaid agency or counsel before writing any deposit policy that touches Medicaid patients.
Can we charge patients whose Medicaid lapsed?
State rules on billing Medicaid patients are strict and depend on whether the patient was eligible on the date of service. During a reconsideration period the answer is usually to hold the claim. Ask your state Medicaid agency or counsel before adopting a policy. The Revelrex denial management team works eligibility denials as a distinct category with payer redirection built in, and our earlier article on eligibility verification workflow covers the standard process once your electronic checks are running again.
What to do this week
- Tag tomorrow's schedule into the three tiers and check every Tier 1 patient this afternoon, recording the portal reference number in the appointment note.
- Add the renewal-letter question to the scheduling and check-in scripts, and print the reconsideration, marketplace and CHIP handout.
- Pull all denials since March 1 with codes CO-27, CO-22, CO-109 and PR-31, sort by charge amount and date of service, and rebill the February dates of service first.
- Ask your clearinghouse, primary or secondary, for the list of payers currently responding to real-time eligibility, and take those payers off the manual list.
- Set a 45-day follow-up task on every claim held for a patient in a Medicaid reconsideration window.
