When a patient arrives for an appointment and their Medicaid has lapsed, the damage is already done. A gap in coverage that could have been caught weeks earlier now disrupts care, delays billing, and leaves a frontline worker scrambling to figure out what happened. The workflows that are supposed to keep patients enrolled in Medicaid are fragmented by design: siloed across departments, dependent on manual hand-offs, and largely invisible to the people best positioned to intervene.
Starting with the Problem, Not the Solution
Our team came to this work with firsthand clinical context. As practicing physicians and case managers, we live inside these workflows. We know what it feels like to discover a patient’s coverage status as a vague flag in the EHR, or from the patient directly. We know the navigator who is also managing social needs referrals and a voicemail inbox full of messages from patients who don’t know where else to turn.
But for this project, we didn’t assume our experience was universal. We conducted structured interviews with navigators, financial assistors, case managers, billing staff, and IT teams at CCBHCs, FQHCs, and hospital systems. We also drew from look-back analyses with existing customers, examining six months of billable encounters that had never been billed and tracing what had gone wrong, and at what point in the process, for each one.
What emerged was a picture of a workflow that no single person owned, at any stage.
How the Workflow Actually Works
The eligibility check no one shares
Medicaid eligibility checks (the 270/271 transaction) are typically run by IT, billing, or revenue cycle teams. In many organizations they’re integrated into the EHR, though the quality of that integration varies considerably: some systems surface clean, up-to-date information; others return data that’s quickly stale or hard to interpret.
Because there is a per-transaction cost to eligibility checks, access is deliberately limited. Batch lookups are done sparingly; individual lookups happen on a schedule. Frontline staff typically have no access at all.
Information that goes nowhere standard
Once eligibility is confirmed or flagged, there is rarely a standard protocol for what happens next. The result might surface in the EHR, appear in an Excel report routed to the insurance navigator or access team, or simply remain with billing for internal revenue-cycle purposes. By the time a navigator learns that a patient’s coverage has lapsed, it may have been weeks. Worse, the patient may already be sitting in the waiting room.
A fragmented frontline response
Organizations employ a range of staff to help patients with insurance: state-certified CAC navigators, internal case managers, financial assistors, front desk staff trained informally. Often it is some combination of all of these, with overlapping responsibilities and inconsistent training.
What these staff members actually do when they encounter a patient without coverage varies just as widely across organizations. Some provide education. Some screen for eligibility and walk patients through online applications. Some serve as authorized representatives. Others, stretched thin or uncertain of their scope, refer patients elsewhere or hand them materials and hope for the best.
In our interviews, this variability came through clearly. One navigator at a CCBHC described printing paper applications and sitting beside patients to complete them by hand, because the state portal was too difficult for patients to navigate on their own. Another, at a busy FQHC, had a different problem entirely.
By then, they’ve already missed an appointment. Sometimes two.
The patient experience
Patients receive renewal notices by mail or email. These are frequently missed, confusing, or both. State Medicaid portals vary in usability, and nearly all require two-factor authentication, which has been shown to be a barrier for elderly patients and those with limited digital literacy. Supporting documents typically need to be hand-delivered or uploaded to the state portal directly.
Meanwhile, the methods navigators use to communicate with patients are just as heterogeneous as everything else: EHR patient portals, desk phones, personal work cells, and the occasional walk-in visit. Many do not allow patients to email them for HIPAA compliance reasons.
What We Built and Why
Understanding this fragmentation shaped every decision we made in designing MediKey. Rather than addressing one piece of the workflow in isolation (just eligibility, communication, or reminders), we built a platform that enables any staff member to complete the entire process, end to end.
Proactive eligibility monitoring
Direct integration with Medicaid eligibility data allows unlimited individual and batch lookups without per-transaction barriers. Coverage gaps can be identified a month before a patient's next appointment, triggered in real time when someone presents in the ED, or surfaced through regular monitoring across an organization's entire patient panel.
A screening wizard that carries the policy knowledge
Walks workers through the questions required to determine eligibility for every applicable Medicaid program, including MAGI, CHIP, pregnancy pathways, LPR pathways, working-disabled pathways, emergency Medicaid, LTSS, and others, and routes them to the correct track. Workers don't need to hold all of this policy knowledge in their heads.
Guided application completion and document guidance
For each eligibility track, MediKey surfaces exactly what documentation a patient needs to collect, pre-fills paper applications where organizations prefer that workflow, and provides next steps alongside relevant regional contacts.
HIPAA-secure communication, built in
Two-way secure text and calling, integrated into the platform, gives navigators a compliant channel for reaching patients. Documents can be uploaded directly into the case. The exchange stays in the record: convenient and defensible.
Recertification triggers and task management
Automated reminders alert staff ahead of deadlines. To-do lists track what's needed for each patient. The system surfaces what step comes next and who is responsible for it, preventing the stall that typically happens in the weeks before recertification.
A shared activity log
Every outreach attempt, document upload, and conversation is logged in a shared activity feed, visible to any authorized team member. In organizations where navigators, supervisors, billing staff, and case managers each have partial views of a patient's coverage situation, this shared record makes hand-offs cleaner.
The Bigger Picture
The Medicaid retention problem is not, at its core, a technology problem. It is a coordination problem, one that technology has historically made worse by adding systems without adding coherence. We heard this from nearly everyone we interviewed: the issue isn’t that there are no tools, it’s that the tools don’t talk to each other, and the workflows don’t connect.
What we also heard consistently is that frontline workers want to do this work well. They want to catch coverage gaps before they become crises. They want to know what documents a patient needs before the appointment, not after. They want a way to reach patients that doesn’t require giving out a personal number.
We built MediKey to meet those workers where they are, and to make the path from coverage gap to enrollment as short and clear as possible for the patients who depend on them.
Because the underlying architecture applies to any structured public benefit program, MediKey is extensible beyond Medicaid. The same logic that routes a patient to the correct Medicaid pathway can be applied to SNAP, LIHEAP, housing programs, and others. Patients don’t experience their benefits as separate systems. They experience them as one complicated life. We’re building toward tools that match.
Related reading: H.R. 1 and what it means for Medicaid retention →