Setting up a building with proficiencies in working with managed care payers is a key to success at this midpoint of the 2020s. 

Fifty-one percent of Medicare-eligible Americans are covered by Medicare Advantage (MA) plans. Nationwide, MA is projected to reach 59% penetration by 2030, which is also when the Centers for Medicare & Medicaid Services wants all traditional Medicare beneficiaries to be covered by some form of accountable care relationship.

Our industry is in a permanent shift toward a managed setting that requires us to adapt to change. 

Right now, it’s vital to establish at least a baseline proficiency for working with managed care payers on the MA side of your census. Baseline proficiency is the first step to aligning your facilities on a path to continued profitability. 

Be unafraid if you’ve been feeling that it’s almost impossible to get the reimbursements you deserve. Many of us are at a point where we’re rationalizing payer pain points with, “That’s managed care. What can we do about it?” 

This is a normal — but unhealthy — mindset. You can and have to put systems in place to succeed as our industry shifts away from FFS.  

It really is normal.

We talk about this topic often throughout the nation, and in Q&A, we usually encounter a sense of confusion about how to get started. When presented with the question of being ready for this huge shift to managed care, audience members frequently have comments such as, “We don’t even know where to begin. It’s overwhelming.” 

They want to know, “Is our ship headed in the right direction?” More so, “How do we know if our ship is equipped with the right tools and resources to successfully get us to where we want to go?”

Well folks, now is the time to shake it off, clear your thoughts, and see the path forward. If you can establish a baseline, you have nowhere to go but up. 

What is baseline proficiency? 

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. 

Contracts are important for two main reasons: access to increased census and updated reimbursement to managed care members. Baseline proficiency with contracts should include the following: 

  • Copy of contract, accessible to all disciplines in need, i.e. admissions, director of nursing, business office, case manager, MDS resource, director of rehabilitation, marketing.
  • Updated contracts: Are they more than a year old? 

Again, when talking about baseline proficiency, we are talking about the fundamental bare minimum of what’s required to succeed with managed care. Focusing on the above points will get you there. 

Case management requires access to a contract, understanding the contract, and daily review of the patient’s chart. These three components round up baseline proficiency for case management. These base proficiencies tend to be a more difficult vision for most operators, as the function of case management is less familiar. With a dedicated case manager, a provider has a higher probability of getting accurate reimbursement from the payer. 

Finally, effective Communication is the third vital element. What is needed for baseline proficiency when it comes to communication?  

  • One point person to follow the process through.
  • Chosen method of communication and team training. This could be through emails, a managed care software application, morning standup, or written forms. The procedures of communication, via the chosen method, are essential. 
  • Accountability for the team to follow the process in a timely, accurate manner. 

After we establish our baseline, how do we keep the managed care momentum going?  

Once you get your team up to speed and working with baseline proficiencies, the next step is to implement best practices. This step is an important one, but it’s less effective when implementing before a team feels baseline proficiencies are second nature.  Success with managed care payers requires a complete commitment to change, and baseline proficiency is the critical first stage to winning this era.  

Susie Mix, BS, MBA, NHA, is the founder and CEO of Mix Solutions Inc. She has more than 20 years of experience in the post-acute care industry. Mix has been doing managed-care consulting with facilities since 2009. She can be reached at [email protected].  

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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