We’re seeing some Medicare Advantage plans change to payment by “levels.” What can we do to ensure we’re being reimbursed accurately?

Managed care contracts can be difficult to navigate, and you’re likely seeing more than ever before. The first step is thoroughly reviewing and understanding each contract and its differences. What are the authorization requirements? Does the plan pay by PDPM? RUGs? Levels? What is covered? 

For plans paying by levels, you will have to identify what each includes and manage the patient daily for any type of level change. PDPM reimbursement is reliant on information from the MDS; levels are not. Daily case management will be your key to success. 

For example, a “Level II” for a given plan might include less than 90 minutes of therapy per day, no less than three days per week. But what if the individual needs more? What if he or she experiences a condition change and requires IV medication — a “Level III” service? Failure to identify these changes or communicate with the plan provider are reimbursement risks. 

Many facilities rely on the MDS coordinator to fulfill the case manager role. Determine if it is appropriate for your circumstances, considering the volume and types of managed care beneficiaries you serve. SNF managed care responsibilities can include:

• Reviewing contracts

• Following authorization/extended authorization requirements

• Identifying and reporting exclusions 

• Monitoring approved therapy limits

• Evaluating changes in conditions/services and communicating them

An interdisciplinary approach and ongoing communication will lead to successful outcomes. Have effective systems from admission to discharge.

And when necessary, don’t be afraid to appeal!