We recently had the pleasure to sit down with Steve Shain, LTC Ally’s EVP of Contracting, to discuss all things managed care, contracting, and more. Hear what he has to say about the state of managed care, what operators should expect, and how important Medicare Advantage plans have become for long-term care operators.
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MUST-KNOW: MANAGED CARE CONTRACTING IN LONG-TERM CARE
Q. What do long-term care operators need to know about managed care contracting and managed care organizations (MCOs)?
Managed Care used to be a very small focus for operators because the primary feeder to facilities was typically Medicare and Medicaid. As both states are transitioning to Managed Medicaid and Medicare is transitioning to Medicare Advantage plans, long-term care operators are seeing that their census is comprised of a lot of managed care and it’s only growing. Right now, Medicare Advantage enrollment for Medicare beneficiaries is close to 50% and growing, so it’s become more of a force than it ever was.
Q. What are the advantages for operators getting in-network with managed care payers?
Getting in-network with a managed care payer is increasingly important for any healthcare provider or long-term care facility focused on increasing its census. What can happen, however, is a provider will try to admit a referral, but find out their contract doesn’t cover certain plans, and they have to turn that referral away.
Getting in-network requires an understanding of which plans are going to benefit the provider and their referral source and ensuring these plans are covered in the contract with the payer. Knowing a provider’s door is open to accept any referral bolsters their relationships with their referral sources.
Q. What can a provider do if they want to accept a referral but realize the patient’s plan is not covered in their contract?
For the most part, when this happens it’s too late. There are certain scenarios where we can get single case agreements or one-time exceptions made by the insurance company, but typically those are only done when a relationship has already started and you’re already well into the process and know there’s a contract coming in a few weeks.
The right way to deal with this is working preemptively, understanding which insurers you need to work with and which plans you need to participate in. The entire contracting process can take months, so planning ahead and getting the process going well ahead of time is vital to being able to admit new referrals.
Q. Are there advantages to already being in-network with one payer when an operator is looking to get in-network with another?
There are occasions when one in-network contract can help you secure contracts with other payers. Usually, each payer has similar credentialing criteria, which shows that you pass the bar in order to be accepted as a worthwhile provider. That’s a sign that another insurer may also use to recognize you in regards to being a provider that will benefit their members.
Being in-network with multiple other payers has its own advantages. We try to use it as a litmus test in regard to the rates that are being reimbursed. One of our areas of expertise is helping providers get rates that are more in line with what’s established in their contracts with other payers. We can talk to a new payer and more closely match existing rates when providers are in-network with several other payers.
MANAGED CARE CONTRACTING: NEWS AND NOTEWORTHY
Q. What’s happening in managed care more broadly that operators need to know about?
One piece of managed care that is getting a lot of attention now—from both the government and payers—is the clinical authorization portion of their interaction with providers. It’s always been a very big headache. Providers are trying to deliver care that they feel is necessary, but the payer has certain protections in place to make sure that they authorize services and make sure there aren’t any providers taking advantage, or not providing the correct services.
Because of the delays and denials that have been happening, there’s been an increasingly large focus on trying to alleviate these issues in order to improve the turnaround time and criteria needed to get authorization. It’s refreshing to see CMS [Centers for Medicare and Medicaid Services] and third-party entities working with insurers and partnering up to create software solutions that can speed up the process while still being robust and providing the needed oversight.
Ultimately, we want to see a process where authorizations are streamlined so they can provide the care they’re trying to deliver as soon as possible.
Q. What’s new in LTC Ally’s Managed Care Department?
One of our newest capabilities is around authorization maximization. This begins where a standard authorization would end. In a facility, that is typically an authorization that will allow a patient to have their stay continued.
At LTC Ally, our MDS nurses go beyond that. They review clinical documentation from when a patient arrives and throughout their stay, and identify diagnoses and additional treatment that the patient received or is anticipated to receive. This allows them to extend the patient’s stay and increase the level of reimbursement. It’s tapping into something the insurer is willing to provide and interested in providing.
Unfortunately, it can be hard to have the right set of eyes reviewing every patient’s clinicals. Sometimes this means facilities aren’t able to capture the reimbursement or allow the patient to get the additional care they deserve. We have been very successful in allowing our client facilities to utilize these maximization techniques. We’re also working on building out software that will help identify these opportunities and reach the levels of care and reimbursement that should be coming to these providers.
Q. What kind of technology are you developing in the Contracting department?
Our software development team, along with our CTO, are working very closely with us to build custom software that will bring our clients insights into where they can maximize authorizations and access live contract data. This solution will also help marketers, admissions staff, and the business office have everything at their fingertips and support impactful decisions.
We are already utilizing software that does this on a very functional level, but we’re working on making this much more robust and accessible, so anyone who needs it will have a dashboard with very clear information. In practice, when a change of ownership occurs or throughout the lifecycle of a managed care relationship, both the clinical and financial staff will have everything in a single online platform. This will give our clients a level of clarity they have probably not seen before.
CONTRACTING AND CHANGE OF OWNERSHIPS (CHOWs)
Q. What should operators expect from the enrollment process with Medicaid and Medicare during a change of ownership?
During a change of ownership, it’s important that providers realize two areas need real attention in order to know how they’re going to proceed when dealing with Medicare and Medicaid enrollment. Firstly, know the state you’re operating in—each state has different rules and regulations. This is especially important in regard to whether you’re allowed to utilize the previous Medicaid number or whether it gets approved retroactively. Sometimes you can only get your Medicaid approval once Medicare is approved, which will affect timelines and cash flow.
Secondly, understanding the operations transfer agreement is critical, which is the agreement between a seller and a buyer when there is a purchase taking place or a change of ownership. Regardless of what the state allows, there may be limitations or liabilities that a seller puts in place that restrict the buyer from utilizing previous provider numbers.
It’s incredibly important for anybody that’s going through a change of ownership to do their homework on state regulations and their transfer agreement. Alternatively, operators can outsource this process to a trusted third party with the necessary expertise.
Q. How do you get facilities in-network with managed care payers during a change of ownership?
At LTC Ally, we make the most impact by helping providers through change of ownerships from the very beginning, whether they’re entering a new area or they’ve just purchased their first facility. In addition to helping providers get in-network, we also help staff understand new admissions and billing processes. We work very closely with providers and their back offices to ensure any disruptions to their accounts receivables are minimized during the change of ownership.
When it comes to getting facilities in-network during a CHOW, we take a phased approach. When the process begins, you have to start new contracts because it’s a new entity. We start by identifying which payers the facility needs to be contracted with. A dedicated team assigned to the provider will look at the facility census and prior contracts under previous ownership and look at the local market to know which payers are prevalent.
Once we determine which payers an operator should be working with, we begin reaching out to payers. Doing this well ahead of the change of ownership is important for a variety of reasons. We work with payers during the interim period while a contract is being set up to ensure there’s an arrangement in place prior to the transition that doesn’t impact the care of residents who are already in the facility.
If a resident has to leave the facility, go to the hospital, and be readmitted, we work with the payer to make sure they can be admitted again. We’ll also work to allow the facility to accept new admissions. This enables facility operations to continue without interruption. We work very closely with payers during this time, so billing and reimbursements continue in a timely manner and don’t impact cash flow. We want to make sure facilities can hit the ground running as soon as the change of ownership is completed.
Q. When is the right time for an operator to reach out to you before a change of ownership?
From the insurance company’s perspective, they want to find out as early as possible about an upcoming change of ownership so they can start doing the legwork on their end. In general, you can never be too early. We tell providers to come to us as early as possible and give us as much information as possible. We’ll reach out to the insurance companies to try to do whatever we can preemptively to get the ball rolling.
Typically, we’re doing this about a month before the change of ownership. On the authorizations side, we start that a bit closer to the CHOW, since it’s more a moving target as to which patients are in-house and which are not, and which ones need arrangements.
Ultimately, it’s important for providers to realize it’s never too early to reach out and start the conversation. As long as the information is gathered and being worked on, it’ll make the process much easier when they get to the actual point of transition.
Q. What elements impact whether a change of ownership becomes more complex or time-intensive for LTC Ally’s Contracting department?
Everything we do is a la carte. Some providers are coming to us just for contracting. Others require the full gamut, including their licenses and getting them enrolled with Medicare and Medicaid—which really is an expertise in itself.
For example, we have specialists whose sole focus is provider enrollments because there are so many nuances within each state, and regulations are constantly changing. Medicare recently changed the entire operation and flow of how a new provider gets approved. Instead of going from the state to the federal level, then going back to the state, it’s now staying at the state level. On top of that, there are so many details that need to be followed in each state’s licensure process to ensure a provider can actually get approved and licensed.
There’s a lot of expertise required to know how each party is providing the right information, and you need to get it right the first time around. Sending in corrections wastes a lot of time and is completely avoidable.
We try as best as we can to have each state and every scenario covered so that when we submit, we get it right the first time. This is how we can expedite the approval time and ensure facilities are ready on day one.