Managed Care – A Long Term Care Game Changer

Managed Care is a game changer for the Long Term Care industry. Traditional Medicare and Medicaid payer sources are being replaced by Managed Care Organizations (MCOs). In the coming years, the impact of Managed Care is going to be huge. MCOs are going to play an integral role in Skilled Nursing Facility (SNF) workflows. MCOs have a whole new set of rules that providers need to be aware of. These rules are specific to each MCO contract and to each patient.

Similarly in 1998, the rules of the Prospective Payment System (PPS) changed our workflows. We had to rethink how to effectively treat patients while being reimbursed at the correct rate. Prior to 1998’s PPS rules, we submitted claims based on our costs. Everything changed when PPS began. Rather than being billed based on costs, we were being billed based on the Reimbursement Utilization Group (RUG).

This shifted the documentation importance from cost reports to the MDS. The MDS coordinator became a crucial role within a Skilled Nursing Facility (SNF). In the same way, Managed Care Organizations are shifting the importance of documentation from MDS Coordinators to a Case Managers. As Managed Care for Long Term Care becomes more prevalent in all markets, having a Case Manager in charge of Managed Care cases and reimbursement is going to becoming increasingly important.

A major challenge for Case Managers is that every MCO contract is different. Reimbursement for the MDS follows the same rules for each patient. Each facility juggles multiple contracts serving different beneficiaries. Some facilities have upwards of 25 different contracts that they need to understand. Facilities must find a way to effectively manage these contracts and map the care given to the level of reimbursement the patient is approved for. Also, case managers need to make sure that all their patients have an approval for the span of their stay. Any small oversight might result in unpaid days.

Currently, many facilities think it is manageable with only one or two of the patient census on Managed Care, but in markets like California, Managed care is becoming the majority. This trend will continue to seep into the rest of the nation and SNFs need to be prepared.

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