Skilled nursing facilities could lose big money if they don't hire a managed care coordinator, exper

Skilled nursing facilities stand to lose substantial sums of money as they increasingly do business with managed care plans, unless a coordinator is on top of exclusions and other contract elements, a prominent healthcare consultant told an audience Monday at the American College of Health Care Administrators annual meeting.

The trend toward managed care has been observed by many leading voices in long-term care. While there are various models for managed care, the basic idea is that a private insurer manages people’s Medicare and Medicaid benefits with the goals of increasing efficiency and reducing costs. This means skilled nursing facilities must become adept at contracting with health maintenance organizations (HMOs), said Susie Mix, president of managed care and contract consulting company Mix Solutions.

One crucial facet of managed care contracts is exclusions. Certain items, such as pricey medications, can be “excluded” from the per-diem rate that will be paid to the SNF by the managed care plan. In other words, a nursing home can be reimbursed for these items in addition to receiving the standard daily payment. A nursing home that negotiates smart exclusions will therefore have a greater ability to care for high-acuity patients.

However, just having a smart contract in place is not enough, Mix emphasized. She strongly advocated for hiring a managed care coordinator to ensure that the SNF actually bills for excluded meds or services and gets the proper reimbursement. With complex contracts in place, it’s very easy for this sort of detail to fall through the cracks, resulting in the facility leaving hundreds or thousands of dollars on the table, Mix said.

A standard HMO contract also usually groups patients into different levels determined by the complexity of their care needs, Mix explained. A person receiving post-acute skilled care might change level several times during a stay, as he or she experiences improvements and setbacks. Having someone to verify that the health plan is approving a patient at the correct level on an ongoing basis is another argument for bringing a managed care coordinator on board, Mix said.

In addition to being vigilant about specific contract provisions, a provider needs to be prepared for how the growth in managed care is likely to change cash flow, Mix stressed. HMOs typically reimburse more slowly than traditional Medicare, and she said certain providers in California have taken out lines of credit just to meet payroll because of this issue.

Mix spoke on the second day of ACHCA’s annual convocation and expo, held this year in Las Vegas. The organization is particularly focused on providing leadership education to enable administrators and executives to tackle the wide range of issues they face and provide the highest quality care, said ACHCA President and CEO Marianna Kern Grachek, MSN, CNHA, CALA, FACHCA. She is particularly excited by the diverse demographics at this year’s meeting and the “bridging” of students and novice leaders with seasoned professionals and highly respected experts, she told McKnight’s.

The event is scheduled to conclude Wednesday.