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Baseline Proficiency for Success with Managed Care Payers
Contract exclusions and the pressure of leveled contracts...
" Baseline proficiency is the result of breaking down the complexities of managed care into three fundamental elements that form an essential workflow. This workflow becomes the foundation to build sustainable success with managed care cases. The three elements are contracts, case management and communication...."
See the full article at: Baseline proficiency for success with managed care payers - McKnight's Long-Term Care News (mcknights.com)
an insider's guide to managed care contract exclusions 12/23
Contract exclusions and the pressure of leveled contracts...
" In recent years, most health plans have shifted to using Medicare Advantage contracts that define levels of care (usually four) that specify a per diem reimbursement rate for each level. The exclusions list details the medications and treatments that are not part of the contract levels. These leveled contracts, with exclusion lists, put pressure on providers to adapt their workflow to accommodate managed care reimbursement rules. No two contracts look the same, which adds insult to injury with an already overwhelming and complex new challenge for providers. Here are four steps to optimize your chances for full reimbursement. "
See the full article at: An insider’s guide to managed care contract exclusions - McKnight's Long-Term Care News (mcknights.com)
Mcknight's: Staff Shortages - What's The opportunity? 10/23
Merge staff workflow and tailored software to become your fundamental answer...
" Collaborative teamwork becomes a resilient foundation that supersedes any individual. Team members use tailored software as the reliable footing that keeps everyone in sync and supported. Teamwork and software create efficiencies that help keep folks from wanting to find new work elsewhere. "
See the full article at: Staff shortages — what’s the opportunity?- McKnight's Long-Term Care News (mcknights.com)
Mcknight's: Insurgence of leveled contracts - 7/23
MA in the USA
"To put the Medicare Advantage growth into perspective, there are more than 3,998 MA plans available in 2023, the largest amount offered since Kaiser the Family Foundation began keeping count in 2010. KFF reports that the average Medicare beneficiary in 2023 can choose from 43 Medicare Advantage plans.
Twenty-one states are now at 50% or higher statewide MA penetration, with Alabama and Michigan leading the way at 57% each. Medicare Advantage penetration is projected to increase for years to come. "
See the full article at: Insurgence of leveled contracts- McKnight's Long-Term Care News (mcknights.com)
KFF: "Medicare Advantage 2023 Spotlight: First Look"
Kaiser Family Foundation's Medicare Advantage (MA) Overview
"For 2023, the average Medicare beneficiary can choose from 43 Medicare Advantage plans..." (Kaiser Family Foundation 11/10/22)
"Availability of Plans by Firm and County. UnitedHealthcare and Humana, the two firms with the most Medicare Advantage enrollees in 2022, have large footprints across the country, offering plans in most counties. Humana is offering plans in 89 percent of counties and UnitedHealthcare is offering plans in 84 percent of counties in 2023, roughly the same as in 2022 (Figure 7). About 9 in 10 (92%) Medicare beneficiaries have access to at least one Humana plan and 95 percent have access to at least one UnitedHealthcare plan." (Kaiser Family Foundation 11/10/22)
Susie is in Skilled Nursing News, May 1, 2023
Excerpt from article by Amy Stulick in Skilled Nursing News:
Click here to read the full article on SkilledNursingNews.com
"Fighting for a favorable MA contract...
Mix believes SNF operators need the right negotiator when drawing up managed care contracts to help with an increasingly troubling bottom line.
A lot of health plans come out with the lowest possible rates, and facilities need someone with the knowledge of market rates to negotiate on their behalf.
“Or if you have the time, and you know that information to go head to head with these health plans, I’ve seen some contracts out there that are bearable,” said Mix. “It’s just taking the time to get that contract negotiated the right way, the first time around. I do think it makes a big difference.”
Besides rates, operators want to look at exclusions in their managed care contract too – such exclusions could include paying for wound vacuum devices or low air loss mattresses used in wound care recovery.
Negotiations could also involve definitions of care levels, which then dictates how much reimbursement a facility gets for certain services. It really comes down to any way to make the contract even a little more favorable to the provider, Mix said.
“If you negotiate them as exclusions in your contract, that won’t take from your bottom line anymore; you will get reimbursed for those things,” Mix said of exclusions. “I can’t say that every contract is unfavorable with managed care, it just requires a little bit of fight to get these exclusions added.”
After a contract is finalized, the fight isn’t over, Mix said. Providers need to make sure they’re using the contract to its full potential. “If we forget to bill for all those exclusions we worked so hard to get, we’re back at square one,” said Mix."
Click the pic to read Amy Stulick's story
60 seconds with susie mix
Susie gives us her personal, and professional, insight on Managed Care news and hot topics.
We’re hearing a lot more these days about managed care. Is this a temporary trend?
A: Managed care is being seen as the answer to control our significantly increased healthcare costs. With the magnitude at which managed care is growing and spreading throughout the nation, it is evident managed care is here to stay for quite some time.
Q: Will managed care have a more profound effect on providers or the people served?
A: This is a tough one. I would have to say that although there are several different initiatives and demonstrations going into effect throughout the nation that affect many different residents, the senior population seems to be the one that is feeling it the most. The Financial Alignment Demonstration as well as the Medicare Advantage insurgence has really put managed care at the fingertips of seniors throughout the nation.
Q: What should operators be doing to get ready?
A: Get educated! It is imperative as an operator to know what is going on in your state and county when it comes to managed care. Once you know what initiatives and demonstrations are coming your way, you can get prepared by getting the needed health plan contracts in place and preparing your team for a new skilled mix.
Managed Care Jolt
McKnight's Long-Term Care News
Susie Mix, owner of Mix Solutions, a managed care and contract consulting firm, said it was eye-opening that only 28.4% of respondents reported more than a quarter of their patients were on managed care plans.
“I am a bit surprised that the percentage is not higher for facilities that are seeing 26 to 50% of managed care penetration in their facilities,” she told McKnight’s. “The Medicare Advantage numbers have skyrocketed in almost every state, leaving their mark on skilled nursing census.”
Medicare Advantage enrollment topped 27 million beneficiaries in 2021, representing more than 40% of Medicare enrollees, according to federal data. Mix predicts more states will see increased penetration in 2022.
“More providers are catching on that they have to become savvy with managed care,” she said. “This requires a few things. One, know your contracts. Two, continue to keep the contract updated. Three, designate one team member that is accountable for following the managed care patient throughout their stay (and) four, know how to read and maximize your contract.”
50 Shades of Data: Leveraging Your post-acute care data
Prime Care Technologies
What are some of the key differences between the administration of standard Medicare patients and Medicare or private managed care patients?
With standard Medicare patients, the post-acute care provider is in charge of the stay and the one who dictates RUG rate, how much therapy to give, when a patient is discharged, and so on. There is familiarity with the process as it has been in place for years.
With managed care patient stays, everything is kind of outside of the post-acute care provider’s hands. The provider is given an authorized level dictated by the health plan/med group and is told when the patient will leave the facility, as well as which vendors they will need to use for home health support for the patient. That’s a huge difference that can be hard to get used to.
What types of data do the SNFs who are dealing more with managed care patients need to start collecting and tracking?
The most important thing is to make sure the data in their contracts is not only accessible but being used by everyone in the facility who manages the patient. Take note of exclusions, levels, and acuity in these contracts because it’s going to be critical in managing the patient according to the contract.
Without due diligence on the front end, a patient can coast through our facility, get clinical care, and then go home. The problem is that no one has compared the care being provided against the patient contract – and this is what costs the facility. Assigning one person to manage this process from the get-go is extremely important to getting clinical care in sync with the contract.
When a SNF works directly with an HMO case manager on a patient – what data does the HMO have and what data should the SNF case manager be prepared to provide?
The case manager really just needs a review of what is” skilling” the patient. It should be along the same guidelines as Medicare. The data shared should reflect the patient’s skilled needs and the progress the patient is making with each need.
Developing a standard progress report form helps case managers in facilities gather the appropriate information that managed care case managers want to know. It shows the skill required by the patient (IV administration, therapy, wound care, stage 3, stage 4, etc.) and the progress made with that ailment – the skill is very important.
It’s also important to stay timely – update forms every 3 days. If the managed care case worker wants it once a week, have that information handy and ready for them. And don’t be late.
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