The federal government has granted Medicare Advantage plans significant leeway when it comes to setting payment rates and other rules for skilled nursing facilities. In normal times, the crazy quilt of managed-care policies and exceptions creates headaches for operators and their billing teams.
Amid the ongoing COVID-19 crisis, widespread variations in Medicare Advantage behavior add another potential challenge onto a system already stretched to its limits — and with dire projections about skilled nursing facility finances over the coming months, capturing every possible dollar could mean the difference between quality care and serious danger.
Management and Network Services (MNS) has been compiling routine updates of Medicare Advantage exceptions and requirements related to caring for COVID-19 residents in the skilled nursing setting. While many insurers have extended crucial waivers to providers, each new update from the Centers for Medicare & Medicaid Services (CMS) raises the question: How will my managed care companies decide to handle this?
SNN last week called Jonathan Hoffman, CEO of the Dublin, Ohio-based MNS, to learn about the trends he’s seen across the company’s footprint of 3,000 providers in 39 states — and to figure out which questions remain unanswered.
What are some of the major trends you’ve seen among Medicare Advantage plans’ reaction to COVID-19?
Well, that question is very encompassing. What we take a look at is: What are the Medicare Advantage plans doing to assist providers on the ground for the COVID-19 pandemic? And what we’re seeing is that most of them are waiving the pre-authorization.
Now when I say most, not all — because in the managed care world, you have different types of product lines under each HMO, or under each payer. Your HMO products for some companies like WellCare, they’re not waiving the pre-auth for that. But they are waiving it for their fee-for-service product.
Every payer’s doing something a little different. Most of them are waiving the prior authorization that is typically required when a patient is in the hospital and seeking to be transferred to a SNF. Typically, we have to get the pre-auth prior to the move. Almost every Medicare Advantage plan has waived that, and said: “Please notify us once they’re in the building.” What they’re trying to do is to help the hospitals with discharging, and help the nursing homes with admitting patients quicker during the pandemic.
It is changing, that is the third or fourth update that we’ve sent out and it will continue to change. For example, Aetna in its update says that they will relook at it, and come out with a new policy on April 24. Okay, so we’ve got, what, nine more days until a new policy will be put out to the public? Of course, we’re going to update our providers and our prospects with that information.
United has said their policy is in place until the end of May. Okay, so we don’t expect anything from United until then. Anthem has said up until June 13. If there’s any one thing your subscribers should note, it’s that every plan is doing something differently. So check with the guide or check with your payer, who you have a contract with, prior to taking a patient.
Have you seen widespread flexibility around telehealth among Medicare Advantage providers?
It does vary, but once again, they are opening the doors and following or implementing similar guidelines for telehealth.
The upcoming nuances that we need to be aware of, and all your subscribers need to be aware of, are twofold. The first one is: If a patient does not need to go to the hospital to be covered under a Medicare Advantage plan as skilled, they never have had to go to the hospital. The three-day [stay rule] has already been waived by Medicare Advantage plans. Under the pandemic, CMS has said you don’t need a three-day hospital stay anymore.
How does that affect us? Well, it doesn’t affect Medicare Advantage at all, because most Medicare Advantage products waive the three-day hospital stay. You could be admitted from a doctor’s office; you could be admitted from home health coverage to a contracted provider prior to the pandemic. So the question now is: What Medicare Advantage plans are putting out skilled care criteria for someone that is already in a nursing home, is one of their beneficiaries or enrollees, and they qualify for skilled care? So that’s a question MNS has been asking and searching for answers for.
MNS operates in 39 states. We have about 3,000 providers that are contracted with us, and we find that Texas is taking the lead — in that some of the Medicare Advantage payers are saying yes, let’s skill in place. If we have to put someone on pain meds or IVs or isolation due to the pandemic, we’ll cover them for that. We have not yet seen that in other states. We’re looking for that to be interpreted by each plan, by each UM [utilization management] program, that each plan employs. So that’s one nuance.
The other one is: CMS rolled out with waivers for transferring patients between locations, either in order to cohort those that are not symptomatic of COVID-19, or to put all those people together that do have COVID-19. And if you noticed in the CMS update, it said it can be in a non-licensed, non-certified building. The question now is for the Medicare Advantage plans to say: Our contract with you stipulates that it is a certified, licensed health care facility where the patient is receiving service.
Well, wait a second, CMS just waived that, but the Medicare Advantage plans have some latitude. So we’re looking to them to answer the question: Will you still skill in place if it’s not in a licensed building, because of the new CMS waivers? That’s an answer that, as soon as I get, I’ll call you back with the answer. We haven’t seen any Medicare Advantage plan interpret that, or give us or provide guidelines to SNFs regarding that. .
This crisis has really revealed some of the tension between state and federal regulations.
Tension does exist between the federal and the state. We’re all looking for leadership to step up and say: If we lead the way this way, you’ll be taken care of; then I think everybody will fall behind.
But when you don’t have agreement between federal and state, then issues or problems, at least of interpretation, can arise. You have federal and state interpretations, but don’t forget — Medicare Advantage plans, while following Medicare guidelines, do make their own determinations in many instances, as far as who’s in network, who’s out of network.
A few the payers have said, even if you’re out of network, go ahead and take the patient. Anybody that deals with managed care knows that an HMO patient, not in a contracted building with that payer, will have a heck of a time getting that bill paid — I mean a heck of a time — because most HMO products do not have an out-of-network benefit. Even though CMS says all of this is waived, or even if a Medicare Advantage plan itself says these guidelines are waived, the issue comes down to: What happens on the ground when the bill goes in for the care?
Most people in managed care know the difference between an HMO, a PPO and a point-to-service product, and the guidelines for each, and what it takes to get paid for an out-of-network HMO is very, very difficult.
Is that an issue right now, bills not being paid?
I’ve had that question posed to me by a state association in the last week. Our company does quite a bit of billing to Medicare Advantage plans. The question that was posed to me by the association was: Have you seen a slowing down of bills getting paid?
And the answer on our side is absolutely not. We have not seen a slowdown at all. Typically, if the bill is submitted correctly, timely, with the correct authorizations, we are seeing anywhere from an 11- to 15-day turnaround time from the payer.
When we take a look at any provider, there are different nuances as to how different providers operate. Some people will bill a claim the first available day that it’s eligible to be billed, which by contract is the day after discharge. However, many providers wait until the end of the month, and then they bill the following month for the month that just ended.
So if you were to ask me, are there are there different nuances in billing? Certainly there are. What we find, most of the time, is that our providers are very interested when they find out that they can bill quicker and get paid quicker by working with MNS. We have found that to be true, and we have not seen a slowdown in payment in at least the last four or five weeks.
Anything else you’d like to share with our readers?
I think one of the paramount things that we all need to do together is continue to share information, because there’s not enough time for everybody to be an expert all the time, and to decide what’s important and what’s not. That’s why MNS developed the COVID-19 payer updates, so that people can access that — we’ll send out updates as we receive updates. It could be once a week, it could be twice a week.
The last edition was dated April 2, and there’s not been a lot of changes since then. We do see more changes coming up. So the words of advice that I have for all providers is: Share information right now. Now’s not the time to try and develop certain expertise in managed care. Now’s the time to focus on the patients and our staff.
This interview has been edited and condensed for clarity.