Q. What do long-term care operators need to know about managed care contracting and managed care organizations (MCOs)?<\/strong><\/p>\n\n\n\nManaged 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\u2019s only growing. Right now, Medicare Advantage enrollment for Medicare beneficiaries is close to 50% and growing, so it\u2019s become more of a force than it ever was.<\/p>\n\n\n\n
Q. What are the advantages for operators getting in-network with managed care payers?<\/strong><\/p>\n\n\n\nGetting 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\u2019t cover certain plans, and they have to turn that referral away.<\/p>\n\n\n\n
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\u2019s door is open to accept any referral bolsters their relationships with their referral sources.<\/p>\n\n\n\n
Q. What can a provider do if they want to accept a referral but realize the patient\u2019s plan is not covered in their contract?<\/strong><\/p>\n\n\n\nFor the most part, when this happens it\u2019s 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\u2019re already well into the process and know there\u2019s a contract coming in a few weeks. <\/p>\n\n\n\n
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.<\/p>\n\n\n\n
Q. Are there advantages to already being in-network with one payer when an operator is looking to get in-network with another?<\/strong><\/p>\n\n\n\nThere 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\u2019s a sign that another insurer may also use to recognize you in regards to being a provider that will benefit their members. <\/p>\n\n\n\n
Being in-network with multiple<\/em> 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\u2019s 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.<\/p>\n\n\n\n
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