Navigating the Medicare Advantage Payment World

 Bundles / Financing 

Athens Regional Home Health, Athens, Georgia.
Agency Description:
Athens Regional Home Health (ARHH) is a Medicare-certified Joint Commission-deemed status-accredited home health agency serving five counties, covering approximately 1,200 square miles in northeast Georgia. The agency began operations in 1998 as the result of a lawsuit appealing the denial of a Certificate of Need application for the underserved vulnerable home health population. Average daily census is 150. An associated home-infusion pharmacy, also with an average daily census of 150, covers a 15-county area.
Population Impacted:
A trend was noted with patients electing coverage through Medicare Advantage (MA) plans. ARHH began contacting these plans to continue to serve patients on a case-by-case basis through letters of agreement. Eventually, MA volumes grew to the level that contracts were negotiated. The agency continues to negotiate rates on a case-by-case basis for patients having plans whose penetration is not high in the region they serve, but this practice has significantly decreased as MA plan penetration has increased. ARHH also leveraged the negotiation power of their associated regional medical center to keep MA reimbursement rates the same as traditional fee-for-service Medicare episodic rates.
Strategic Partners:
Athens Regional Medical Center's Director of Managed Care worked with ARHH Director of Business Operations and Executive Director to assist with some initial contract negotiations. Athens Regional continues to leverage the facility’s power during the negotiation process with new MA plans to keep them informed of their agency's outcomes and services offered.
Project Description:
Increase MA payer mix while maintaining profitability by negotiating episodic rates with MA plans, either contractually or through case-by-case rate negotiations based on traditional fee-for-service Medicare reimbursement methodology.
In calendar year 2006, ARHH MA payer mix was 5.2 percent and increased to 22 percent in 2015. Net profit has remained positive for this group.
Outcome Measures:
Outcomes for the Medicare Advantage population are similar to those of the Medicare traditional fee-for-service group. Athens Regional has noted patient satisfaction scores slightly lower in the MA population, although the decrease has not been significant. The agency has been unable to determine the cause since other MA patient characteristics mirror those of their traditional Medicare beneficiaries.
Barriers to Implementation:
There are several barriers to successfully negotiating the MA market. The first barrier is often the hardest and that is in reaching the right individual at the MA plan to begin the contract negotiation process. This is where utilizing contacts of the parent medical center provided an advantage. 

Plans have traditionally pursued negotiation of a per-visit reimbursement and attempted to include contract language outside traditional Medicare regulations. Thus far, they have been successful in blocking these efforts. As plan reimbursements decline, more pressure will be brought to bear to negotiate a different reimbursement structure or move to a risk sharing model. Understanding how CMS measures and reimburses MA plans for quality and beneficiary satisfaction is critical to leveraging better reimbursement rates during these negotiations. Utilizing their patient satisfaction and quality outcomes continues to provide ARHH with a strong negotiating position because these factors are more important to MA plans after enactment of the Affordable Care Act.

Many plans require pre-authorization, reauthorization for visits or approval to add disciplines after admission. Admission assessment documentation and the plan of care usually must be completed and provided to the MA plan within 24 hours of the initial visit. For some plans, additional time is required by office staff to obtain ongoing authorizations and for visiting staff to track visits authorized so they do not exceed visits or add disciplines without first obtaining authorization. These steps add additional administrative burden, so efforts should be taken to remove as many of these requirements as possible during negotiations. ARHH has been able to remove many of these requirements or have them apply only to subsequent episodes. We believe this is connected to our outcomes and patient satisfaction results. 

In the last two years, they have seen increased post-payment audit activity from MA plans. It behooves the agency to keep abreast of individual plan procedures and document request timelines and develop an appropriate appeal strategy. ARHH has elected to appeal all denials whenever possible regardless of amount. Their experience has been MA plan reviewers seem less informed than the more mature Medicare Administrative Contractors. In addition, knowing your rights as a contracted provider versus a noncontract one is a must. And be prepared to fight for these rights, especially if your agency is a non-contracted provider.