To Win Medicare Advantage, Skilled Nursing Must Speak Insurers’ Language

With managed plans gobbling up an increasing share of Medicare enrollees, skilled nursing executives need to gain fluency in the language of insurance providers — or risk being left behind.

That was the message from a recent panel discussion at the National Investment Center for Seniors Housing & Care (NIC) Spring Investment Forum in Dallas, where the rise of Medicare Advantage was a frequent topic of conversation both as a potential strain and an area of opportunity.

“This is our new business, like it or not,” panelist Susie Mix, founder and CEO of Medicare Advantage consulting firm Mix Solutions, said. “Medicare Advantage is not only here, but it’s growing.”

But it’s not as simple as calling up plans and landing partnerships. Medicare Advantage providers’ success relies heavily on their quality and performance ratings from the Centers for Medicare & Medicaid Services (CMS) — which, like the ratings for nursing homes, follow a five-star format.

“We live and die by the star ratings,” said Sheila Strand, vice president of field operations for OptumHealth, a subsidiary of insurance giant UnitedHealth Group (NYSE: UNH) that operates the OptumCare health network.

In order to protect their star ratings, Medicare Advantage programs look to partner with facilities that can both provide solid clinical outcomes — including low readmission rates — and understand how to bill for services.

The latter consideration is easier said than done. Mix suggested hiring a full-time Medicare Advantage point person to handle all the contracts, which are different for each provider, and serve as a one-stop source for information about resident outcomes. Insurance plan employees don’t have the time to hear about the minutiae of a specific resident’s clinical care plan, Mix said; they want direct, concise information, and they want it fast.

“These health plans have a job to do, and you guys making it easy for them, and giving them the right information, is key,” Mix said.

Part of that knowledge also means speaking insurance plans’ language. For example, that could mean an intimate awareness of the Healthcare Effectiveness Data and Information Set (HEDIS), a detailed resource that health plans use to evaluate their own performance — along with consumers and employers.

“To be able to talk to a health plan the way a health plan understands is very important,” Jason Feuerman, senior vice president of strategic development and managed care at Genesis HealthCare, said. “You need to understand what HEDIS means.”

Attracting Medicare Advantage partners also means thinking beyond reimbursements and emphasizing what kind of services you can provide to help the plan, the panelists said — including home health or other ancillary product lines.

“If you keep talking rates, they’re going to cut your rates,” Feuerman said.

Written by Alex Spanko