Embracing managed care

Elizabeth Newman
Elizabeth Newman

At the American Health Care Association conference in 2013, a panelist at a session mentioned facilities needed to start hiring a full-time person to oversee managed care contracts. It was clear that finding these people — adaptable, smart and aggressive — to oversee the revenue around managed care contracts would be challenging.

When I heard Rosemary Angsten, Senior Vice President of Sales and Admissions at Symphony Post Acute Network, speak at the Post Acute LINK conference Thursday in a session on what managed care means for providers, it was clear she was the person providers need. She was the counterpoint to the equally smart Mary Cooley, MS, RN, VP Care Management and Operations at Priority Health, who described herself as a “big bad managed care” person: Her organization has 750,000 members, mostly in Michigan, and excellent results.

The two of them, along with Mike Rusnak, a home care and hospice executive from California, offered specific tips on how providers can deal with Medicare Advantage or commercial plans.

That matters because everyone agrees that the days of a facility saying, “We want only Medicare patients” are coming to an end. Everyone wants those beneficiaries, but in 2016 one in three beneficiaries are in Medicare Advantage. That's about double the size since 2008.

What also was clear from the panel was managed care, skilled nursing and home health have to build partnerships. There's been a lot of talk about building relationships, but often about skilled nursing facilities and hospitals. That is critically important, but providers who send off their forms to a managed care representative with no effort to follow up are the equivalent of a person who signed up for Match.com expecting someone to immediately propose marriage.

In both cases, you have to date, and in the modern world, that means you start with light Google stalking. Who is the managed care person you need to talk to? Turn to LinkedIn, or even ask a competitor. Once you know that individual, introduce yourself in person at a conference. Invite him or her to tour your facility and give the person a reason to want to hear your story. Contracting is relational, and it's up to you to figure out how to build a successful marriage.

“If I took no for an answer, I'd be in no network,” Angsten said. “If you can get the contractors to come and tour, it demonstrates transparency.”

But, as it is in dating, once you have the person's attention, you also have to delve into your numbers. In response to a question from moderator Des Varady about how providers feel that they're stuck with a managed care contract, Angsten said she'll often take a hard stance.

“There will be times when our reimbursement would be the same as if it was a Medicaid patient,” she explained. If the contract is offering X dollars for a Medicare Advantage patient, the facility has to look at what it will cost to treat and make sure it isn't losing money.

Another way providers are losing money is with co-payments. This is especially tricky for those in bundled payment networks with home health. Rusnak said it's a big change for home health networks to collect co-pays up front, but the intake representative needs the credit card information before the nurse arrives.

“Sometimes that $25 is all that is left in your margin,” he said.

For the staff that delve into the nitty-gritty of contracts, pay particular attention to arbitration clauses and the specific rates. To create success, billing also has to be involved with managed care claims, and be squeaky clean.

“If you don't have clean claims, you will hate managed care,” Angsten said.

Another change in the managed care world, Angsten said, is SNF clinical staff whispering to a patient “I think you should appeal.” If there's a clinical case to be made, the facility can do it, and managed care organizations aren't so rigid there aren't exceptions. (They are, however, closed on weekends, as the panel noted, so work with the hospital discharge planner to make sure you're not going to lose money on someone arriving Friday night.) Those facilities telling beneficiaries to appeal on a regular basis are damaging their relationship with the managed care group, and could end up divorced.

To keep the relationship healthy, it's also time to revisit therapy, specifically Therapists Who Love Too Much By Providing Extra Therapy. When a therapist is giving two hours of therapy and the contract says one, that margin disappears.

If all of this seems overwhelming, take a deep breath and figure out what your facility is good at, the panel advised. There will be buildings that are less than three stars where no one is requesting it by name. For those, adding behavioral health or services such as hemodialysis may allow a niche market that allows the building to thrive.

But once again, remember that partnership piece. Successful relationships are built on conversations, not lobbing hateful emails or nasty words.

“It cannot be a battle,” Angsten said. Cooley noted providers may be seeing more churn, but the same census numbers.

“We know you are disrupting, hopefully constructively, your business model,” Cooley said. But high quality care at lower costs is still everyone's aim.

Follow Elizabeth Newman @TigerELN.







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McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Emily Mongan.

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