3 Ways to Curb the Impact of Managed Care

In the world of Long Term Care, managed care has grown at a dizzying pace.  With Medicare and Medicaid Expansion, as well as the Financial Alignment Demonstration (FAD), an increasing number of patients are managed by insurance companies. Not more than 5 years ago, only a few Preferred Provider (PPO) patients and a few Health Maintenance Organization (HMO) patients showed up at skilled nursing communities.

Now small to large providers have a managed care census of 10-25% and are juggling anywhere from 10 to 300+ contracts.

Skilled nursing organizations are losing an average of 20% on their managed care revenues, partly due to ineffective care tracking and billing management. That doesn’t mean you have to.

Here are three things you can do to curb the impact of managed care:

1.      Start at pre-admission – Before admitting a new patient, check to see if the patient has costly medications or other necessary costly treatments. Compare these costly items to your Managed Care contract. Are the items included or excluded in the contract? If there are costly drugs that are not carved out as exclusions paid separately by the managed care company, you may want to get in touch with your insurance case manager to negotiate an exclusion. It is easy to overlook a costly medication that your facility may get stuck paying for if each case is not carefully reviewed prior to admission.

2.      Authorizations are up-to-date –Managed care organizations generally pre-authorize care at a certain care level for a time period. When the time period is up, it is time to get reauthorized. If the patient is not authorized for a certain time period, your facility can lose out on reimbursement. It is important to stay on top of these authorization periods and know when to get a reauthorization.

3.      Track the Level of Care –Make sure that the level of care you are authorized for is the level of care that the patient is being treated at. If you are providing care higher than what the patient is authorized for, call the Managed Care Organization and request a higher level of care authorization. If the patient is being cared for at a lower level than what is authorized, you may be at risk to be audited by the insurance company, who may decide to take that payment back. It is important to track the level of care for your residents to ensure that you are getting reimbursed for all the care you provide.

Recommended Posts