Managing Medicare Advantage Contracts for Profit & Efficiency

Agenda

! Growth and Relevance of Medicare Advantage (MA)

! Operational Challenges

! Strategies for Managing Contracts

! Key Takeaways

! Questions

2September 2020 BlackTree Healthcare Consulting

Growth and Relevance

Medicare Advantage Growth!36% of all Medicare

beneficiaries!Congressional Budget Office

(CBO) projects 51% by 2030!24.1 million enrollees!Increased by 9.5% from 2019 to

2020!Slightly higher growth level than

2018 to 2019

*Source: Kaiser Family Foundation


Medicare Advantage Growth!States with highest MA share:

!Oregon!Minnesota!Wisconsin!Pennsylvania!Florida!Hawaii!Puerto Rico

!New York is above national average, at 39% market share



Medicare Advantage Growth

!Understand the big players when developing MA strategy!Focus on the plans in your

market

!UHC, Humana, and BCBS comprise 59% of all MA enrollees nationally



Medicare Advantage Expansion!Areas of change/expansion

!Adoption of PDGM!Non-skilled home care!Hospice!Telehealth

!MA plans making benefits package decisions 1-2 years in advance!Additional flexibility given during PHE


Adoption of Home Health Changes!Traditional Medicare implemented PDGM on 1/1/2020

!Adoption of billing methodology varying across plans!Communication on transition stronger with some plans vs. others

!Unsure if MA plans will adopt:!Diminishing RAP impact!Notice of Admission (NOA)


Non-skilled Home Care!2019 primarily health-related supplemental benefits added

!Adult day care!Respite care!Safety home modifications

!2020 expansion of benefits for Special Supplemental Benefits for the Chronically Ill (SSBCI)!In-Home support services!Meals, food & produce!Complementary therapies

!361 plan adopted supplemental benefits in some form in 2020 as opposed to 102 plans in 2019!245 plans adopted SSBCI benefits in 2020


Non-skilled Home Care


*Source: ATI Advisory

Hospice Carve-in!Value Based Insurance Design (VBID) demonstration to be

implemented on 1/1/2021!Demonstration to go through 2024!Recent NAHC response proposed delaying until January 2023!CMS to release list of participating plans in the fall!Plans must offer access to both in-network and out-of-network

providers for 2021 & 2022!VBID Model includes:

!Wellness & Health Care Planning, including advanced care planning

!Part C and D incentives and reduced cost sharing programs!Hospice benefit component


Hospice Carve-in!MA plans will be required to provide palliative care to

eligible enrollees regardless of hospice election as well as transitional concurrent care services

!Billing instructions (MLN# MM11754)!Claims will still be submitted to the MACs!No detail provided on whether claims will also need to be

submitted to MA plan!MA plans will still be billed even if provider is out-of-network!Non-contracted hospice will be paid traditional Medicare rates at a

minimum!No clarity on Notice of Election (NOE) requirements, but CMS

indicates 5-day timely filing window would remain


Hospice Carve-in!MA plans cannot require authorization or any utilization

management process that will impede timely access to care

!CMS will allow for auditing measures, but the extent to which these are implemented will be specific to plan

!Example: Prepayment reviews to ensure drugs are covered under hospice benefit and not shifted to Part D

!Example: Prepayment review on long lengths of stay


Telehealth!MA plans have had more flexibility than traditional

Medicare to include telehealth as a supplemental benefit!Have not seen widespread adoption!How will this change as MA benefit packages continue to expand?

!Monitor telehealth expansion in traditional Medicare!Inclusion of telehealth on care plan and cost reports!Still not reimbursed or counted towards LUPA thresholds


Operational Challenges

Revenue Cycle Challenges


Authorization

Orders Management

BillingCollections

Reporting

Revenue Cycle Solutions! Authorization

!Structure staff assignments by payor!Document payor nuances and educate branch locations!Optimize EMR to individualize authorization settings!Negotiate favorable protocols in your payor contract

! Orders Management and Timely Filing!Document timely filing limits by payor!Prioritize billing holds by payor timely filing!Always ask about negotiating timely filing limits


Revenue Cycle Solutions ! Billing Requirements

!Contact account representative to confirm requirements!Ex. PPS vs PDGM!Ex. Home care and hospice requirements

!Track payor denials and adjust EMR setup!Utilize clearinghouse to customize claim format

! Collections!Strategize accounts by adjudication time!Provide education to payor representatives on processing errors!Initiate payor projects


Revenue Cycle Solutions! Financial Reporting

!Expect accounts to age and reserve accordingly

!Establish appropriate DSO expectations!Benchmark 75 days

!Understand your cash flow trends

!Set up specific adjustment codes to report on bad debt contributors!Perform adjustments monthly to understand current

issues and maintain accurate A/R


Strategies for Managing Contracts

Contract Analysis


Assess

•Assess your cost by location and discipline•Factor in additional procedures due to MA

Analyze

•Analyze contract profitability•Determine your net margins based on target cost

Negotiate

•Negotiate rates based on desired margins•What is your value?•Termination is an option

Forming A Partnership!Relationship

!Ease of doing business!Set goals for the partnership

!Engagement!Demographic!Participation in all products/branches

!Value!Social Determinants of Health!Inpatient Readmission Reduction

!Resource


!Contract Renewal!2 year vs. evergreen

!Specialty Programs!Demonstrate value

!Contract Strategy Optimization!Rate Optimization/Negotiation!Look beyond the rates!Value Based and Risk

Arrangements

Higher Rates

Favorable Conditions

Contract Negotiation

BlackTree Healthcare Consulting23September 2020

Contract Management!Payor matrix

!Single page reference tool with key information!Contract repository

!Obtain electronic copies or scan paper agreements!Standard naming convention

!Management of agreements !Fully Executed!Aged Agreements –Renegotiation vs Term !Payor Mix Balance !Credentialing


Education!Skilled Home Health

!Demonstrate value and education on higher acuity care levels !Example: Patient population taking the top 5% noncompliant patients joint venture

cost sharing to demonstrate cost savings and value by using the HH agency

!Non-skilled Home Care!MA population –RN can identify additional services may be needed such as

personal care services/homemaker services !Prevent future illnesses with holistic approach

!Hospice!Prepare your pitch!Focus on early identification and transition

!Telehealth!Program Education and Demonstration

! Focus on patient adoption and gathering data


Key Takeaways

! MA expansion of benefits is leading to fast growth

! Understand the operational challenges unique to MA

! Know your worth

! Be informed and negotiate accordingly

! Providers are key to payor education


Questions?

Brian HarrisConsulting Director

Brian [email protected](610) 536-6005 ext. 732

Chris CardoneChief Financial Officer

[email protected] ext. 667

Managing Medicare Advantage Contracts for Profit & Efficiency

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