Strategies for Success in the Evolving Home Care Landscape
Reimbursement stands out as a primary concern among home care providers. Over time, we’ve witnessed a shift in the landscape, moving from 90%-100% reliance on traditional Medicare to a mix where only 40%-50% comes from traditional Medicare. For those not yet engaging with managed care, this shift has likely impacted their census.
In Florida, we’ve observed a significant rise in Medicare Advantage enrollment. As of April 2024, reports that out of 5,085,559 eligibles in Florida, 2,888,990 are enrolled in one of the many Medicare Advantage plans available. Additionally, there are marketplace, employer, and managed Medicaid plans in our market.
Recognizing the necessity to diversify revenue streams, most agencies are now actively pursuing relationships with managed care plans. Once you’ve identified the key players and attained network status through contracting, it’s crucial to understand how to effectively implement these contracts.
Contracts are signed… Now What?
When selecting plans to work with, it’s essential to address key elements of the contracts, such as:
- Authorization of revenue and Healthcare Common Procedure Coding System (HCPCS) codes.
- Utilization of assistants like licensed practical nurses (LPNs), physical therapist assistants (PTAs), or certified occupational therapy assistants (COTAs), and the corresponding codes.
- Coverage for various lines of business: Medicare Advantage, preferred provider organizations (PPOs), health maintenance organizations (HMOs), dual eligible special needs plans (D-SNPs), institutional-equivalent special needs plan (IESNPs), commercial, marketplace, and/or Medicaid.
- Management of non-routine supplies and preferred vendors. CMS.gov
- Effective date of the contract, especially important for renegotiation purposes.
Understanding these details is imperative to avoid any oversights when accepting patients and obtaining authorization.
While contracts have a specific effective date, updates will be ongoing regardless. To stay informed, it’s advisable for a member of your organization to subscribe to email updates. Provider manuals are typically annual, but updates can be as frequent as weekly. Many health plans offer quick reference guides and produce regular newsletters and webinars containing the latest updates, all invaluable resources for your team.
Managing Day-To-Day Processes
To manage your managed care contracts successfully, it is truly a team effort. Everyone has their respective roles, but collaboration is key.
Intake: When a referral is received, the intake department must verify that the patient’s health insurance plan is one that your agency accepts. To ensure this, the following steps should be taken:
- Review demographics: Can you service the area? Will they be receiving service at the address provided?
- Who reviews clinical documents? Is clinical documentation reviewed before verifying eligibility?
- Identify the primary care physician (PCP) versus the ordering physician. Do they belong to an IPA (Independent Physician Association) carved out of the payer’s contract?
- It is always recommended to verify Medicare and Medicaid eligibility:
- Medicare: Confirm the enrolled health plan and check for any liability claims.
- Medicaid: Identify secondary payers and potential needed services if offering both skilled and non-skilled services.
- It is particularly important to verify eligibility and benefits with the health plan. It is recommended to do this monthly, as well as initially.
- What is your internal process for discussing co-pays? Have you reviewed your contracts or provider manuals to uncover who manages collecting co-pays/co-insurance? Sometimes, the payer oversees this.
Authorizations: Utilize portals if available. Gather all requested documentation and provide a clear outline of your request. Maintain a consistent order when uploading or faxing documents. Upon receiving authorization, ensure its accuracy.
Accurately reporting the referring and authorizing physician is crucial, especially for members with an HMO plan, where the PCP acts as the gatekeeper. Verify that authorized individuals possess the appropriate skill levels and proper authorization.
As the current authorization nears its end, closely monitor the situation and request additional authorization promptly. Waiting until the last authorized visit is not advisable. If an updated authorization is assumed but not received, provide a Notice of Medicare Non-Coverage (NOMNC) to the patient before discharging them.
Case managing health plan patients is a crucial role within your agency.
Claims Filing & Collections: Proper payor setup in your software is a critical first step to ensure clean claims generation. Some electronic medical record (EMR) manuals offer extensive guidance on new payor setup, spanning more than 100 pages. It’s essential that the individual responsible for payor setup is thoroughly familiar with this process. Key elements requiring accuracy in payor setup include:
- The correct benefit plan with the appropriate address for claim submissions.
- The correct claim format.
- Authorization number requirements.
- The correct code set included in the contract.
- The requirement of a Health Insurance Prospective Payment System (HIPPS) code on the claim (yes for Medicare Advantage).
- The timely filing requirements for this payer.
It’s important to note that authorizations do not guarantee payment. Implement systems to verify authorizations before submitting claims. Cross-check the services provided against those authorized. Ensure that you are indeed contracted for the authorized services.
Having a system in place to review and respond to denial notifications or requests for additional information is crucial. If claims are determined to have been billed incorrectly, promptly make the necessary corrections and refile the claim. Regularly review data to identify trends, learn from denials, and establish processes that protect you from identified trends.
By leveraging the many resources available and fostering collaboration within your team, you can successfully navigate the complexities of managed care.
To learn how you can gain market advantage and obtain the strategic advantage you need to thrive with Managed Care Contracting and Credentialing Services from HPS, please don’t hesitate to reach out to us.
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This article was originally published in the Summer 2024 edition of Florida at Home Magazine, the official magazine of the Home Care Association of Florida (HCAF). This article was authored by Melinda A. Gaboury, CEO and Regina Wild, Director of Managed Care Consulting.