With Medicare Advantage on the rise how can your agency knock it out of the park and use it to your advantage? The short stop answer is with implementing consistent processes. When a batter is up to bat, they know which direction to go and what bases they must land on to get to Home Base. It’s no different with Managed Care.

Before you run the bases it is important to know your opponent.


We established in the previous blog that Medicare Advantage saturation across the nation has continued to escalate.  We also discussed that agencies must decide which of the Medicare Advantage Plans they will contract with and the significant things to look for when making that decision.

Now that you have a contract you are only on first base.  There are many things that must be conquered for you to score at home base.

Common items that must be understood about your contract:

  • What revenue codes and HCPCS codes will be authorized?
  • Can you use assistants such as:  LPNs, PTAs or COTAs? Is the same code used for both registered and assistants or is separate authorization and codes required?
  • What lines of business are you contracted for? Medicare Advantage, PPO, HMO, DSNP, IESNP, Commercial, marketplace or Medicaid?
  • How are non-routine supplies handled in your contract?
  • It is imperative that agencies understand all the details so that nothing is missed in the process of accepting patients and acquiring authorization.

To learn more about HPS Managed Care Contracting and Credentialing Services, click here.


It is especially important as most of your questions are answered in the manual. Also, provider manuals & provider updates always trump your contract. While contracts are effective as of a certain date there are going to be updates ongoing that are going to be applied regardless of your contract.  In order to stay up to date with the manuals someone in your organization need to sign up for the updates to be emailed to the team. Many health plans also have quick reference guides, which are incredibly useful.  There may also be routine newsletters and educational webinars, produced by the plans, that will include updates.


In most cases the plans today have provider portals that agencies should be come familiar with. They can save the intake and case management team time when utilized to their full potential. Time means money. The provider portals can be used for eligibility, benefits, initiating authorizations, and checking claims status.

Some portals have interactive features to chat with a representative, so you do not have to waste valuable time with phone calls. Many portals have upload features for required clinical documents or other requested supporting documentation.

After reviewing the contract, manuals & provider portals you will have a clearer understanding of what you are up against. Now that you are at second base, let’s continue around that field.


Intake: upon receipt of a potential referral, the Intake Department must establish that the plan the patient has is a plan that the agency currently accepts patients from. In order to confirm this information, the following should take place:

Review demographics, can you service the area? Will they be receiving service at the address on the demographics?

Who reviews clinical documents? Do you review clinical documentation before verifying eligibility?

It is always recommended to verify Medicare and Medicaid eligibility. Medicare to confirm which heath plan they are enrolled in and confirm that there are no liability claims. Medicaid, to help identify secondary payers. This can also help you identify potentially needed services if you offer both skilled & non-skilled services. Particularly important is 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 is responsible for collecting co-pays/ co-insurance? Sometimes, the payer is responsible for this.

Authorizations: Utilize portals if they are available to you. Gather all requested documentation and include a clear outline of your request. Have a consistent order that you upload or fax documents. Once you receive the authorization, confirm its accuracy.

Ensure it has the five “rights” of authorization:

  1. Right agency
  2. Right National Provider Identifier (NPI)
  3. Right patient
  4. Right services and codes
  5. Right dates of service

If the plan issues an authorization number that must be utilized on the claims, ensure that you receive that number in writing and that it is placed in the appropriate area in the Electronic Medical Record (EMR) to ensure it flows to the claim.

It is important that you report the correct referring and authorizing physician. This is especially important when the member has an HMO plan (Health Maintenance Organization) since the Primary Care Physician (PCP) is the gate keeper. Use appropriate skill levels and confirm they are authorized properly.

When you are approaching the end of the current authorization you should ensure that you are adequately monitoring and initiate the request in ample time to secure additional authorization.  Do not wait for the last authorized visit is being provided to initiate this request.  If you assume you are going to get an updated authorization and do not, you still need to provide a timely Notice of Medicare Non-Coverage (NOMNC) prior to discharging the patient.

We have rounded third base and are heading home!


It is crucial that the payor is set up correctly in your software.  This is the absolute first step to ensuring that clean claims can be produced.  Some EMR manuals include over 100 pages on the process of new payer setup in the system.  You need to be convinced that the person responsible for payer setup in your organization is fully familiar with this process.  Some of the key elements that must be accurate in payer setup:

  • Correct BENEFIT PLAN determined with correct address for submitting claims
  • Correct Claim Format
  • Authorization Number requirement
  • Correct code set that was included in contract
  • Is a HIPPS code required on the claim (YES – for Medicare Advantage)
  • What are Timely Filing requirements for this payer

Remember authorizations do not guarantee payment   Have systems in place to verify authorizations prior to submitting claims. Check services provided against services authorized. Confirm that you are indeed contracted for the authorized services.

It is vital to have a system in place to review & respond to denial notifications or requests for additional information. If it is determined that claims have been billed incorrectly, make necessary corrections timely & refile the claim. Review data monthly to help identify trends. Learn from denials and build in processes that safeguard you from identified trends.


Agencies can not only score when they are successfully applying all that was discussed in this blog, but they can WIN the game with Medicare Advantage and other Managed Care Payers.  Don’t strike out or get thrown out at second base, continue to score and win the game by meticulously reviewing every detail and ensure your entire agency is fully versed in the playbook.

Healthcare Provider Solutions would be thrilled to assist you in every aspect of working through all your Managed Care needs.  To learn more about HPS Managed Care Contracting and Credentialing Services, click here, or Schedule a call today to find out how we can assist.