The growing prevalence of Medicare Advantage (MA) plans in many skilled nursing markets has been a source of mounting challenges for operators, many of whom are wondering whether they can keep up with the change.
Yet a few strategies can go a long way to make the transition work, experts said. They cite leveraging data analytics, fostering inter-provider collaboration, and prioritizing staff education as among the top ways to beat the challenges.
In a recent panel discussion at the CLINICAL conference hosted by Skilled Nursing News in Tampa titled, “Medicare Advantage in Skilled Nursing: Pain and Possibilities,” panelists delved into the complexities and opportunities presented by Medicare Advantage in skilled nursing facilities.
The panel featured insights from Jolene Johnson, VP of Clinical Reimbursement at The Springs of Arkansas; Elizabeth McLaren, Senior VP of Revenue-Cycle, Reimbursement and HCBS at Covenant Living Communities and Services; and Kelly Roberts, VP of Clinical Reimbursement at Creative Solutions in Healthcare.
Appeals consortium
Johnson expressed concerns regarding the significant gap in reimbursement between MA and traditional Medicare, citing a 40% reduction in payment.
Highlighting the struggle to meet regulatory requirements amid declining revenues, particularly in light of impending staffing regulations from CMS, she emphasized the critical need for nursing homes to balance financial viability with quality care provision.
Johnson also discussed the formation of an appeals consortium, which is comprised of 7,000 nursing homes, to collectively address managed care contract negotiations and appeals processes. She highlighted the consortium’s collaborative efforts in sharing resources, such as appeal templates and successful strategies, to advocate for providers’ interests and navigate regulatory challenges effectively.
Provider unity is necessary for negotiating favorable contract terms and ensuring compliance with managed care regulations, Johnson said.
“It’s made a huge difference in the contracts across different states and how we’ve overcome [challenges],” she said.
The evolving landscape of MA regulations requires that providers constantly receive education and adapt in order to ensure compliance and to optimize reimbursements, Johnson said. She underscored the role of physician involvement in navigating regulatory changes and urged providers to stay abreast of updates to advocate for patient care needs.
Strategies for adapting to Medicare Advantage’s growth
Roberts and McLaren said their organizations successfully addressed operational challenges posed by MA, particularly in managing authorizations and streamlining communication, by equipping staff with adequate tools and support to navigate the complexities of MA contracts.
At Creative Solutions, this included access to centralized hotlines for assistance and targeted staff training, Roberts said.
Meanwhile, standardizing intake procedures across facilities to enhance efficiency reduced costly errors in the authorization process at Covenant Living, McLaren noted.
She discussed the implementation of a centralized intake and admissions process across 21 locations. This was prompted by the realization that admissions coordinators excelled at face-to-face interactions but often lacked proficiency in negotiating obligations and technical aspects.
“We had admissions coordinators at our communities who are really good at face-to-face interactions,” she said. “They were excellent at welcoming residents, engaging with families, and securing contracts. However, it’s rare for that person to also excel at negotiating obligations, which is more of a technical aspect.”
By identifying individuals skilled in admissions and separating them from the task of negotiating the technical aspects of a contract, Covenant Living was able to reduce debt in write-offs related to inappropriate authorizations by 80%.
Also, centralizing the intake process and creating a common intake form streamlined the admissions process, emphasizing the importance of timely decision-making and gathering necessary information more efficiently.
“It makes sense to centralize that function and have a call center,” said McLaren.
Negotiation and collaboration
Panelists also discussed the importance of collaboration among providers to negotiate favorable terms for MA contracts.
Johnson emphasized the need for collective bargaining power, citing examples of successful consortiums pooling resources to negotiate better contracts with managed care organizations. McLaren echoed this sentiment, stressing the importance of understanding organizational margins and non-negotiable terms in contract negotiations.
“CMS has released a few FAQs that I find to be incredibly helpful due to the impending changes,” McLaren said. “As providers, we must advocate for our patients and beneficiaries whom we are hearing from. Nonetheless, it must be a balanced approach because we cannot disregard the management aspect, especially with 50% of the eligible population.”
Meanwhile, Roberts underscored the role of data analytics in informing contract negotiations and tracking performance metrics to demonstrate value to managed care organizations. She emphasized the utilization of data-driven insights to highlight quality outcomes and negotiate competitive reimbursement rates.
And, an added plus with creating education around managed care is that it helps with staff turnover, Roberts said.
“From a staff turnover standpoint, we strive to maintain satisfaction and keep them well-educated,” she said. “If there’s a change in your contract, a mass communication is sent out, specifically tailored to that facility—addressing their needs, their proficiencies, and where they might need extra assistance. Many of our facilities have a very low census, so we offer a hotline system to help them navigate and know what to do.”
Harnessing technology and data
In addressing the role of technology, panelists advocated for the integration of artificial intelligence (AI) and data analytics to optimize operational efficiencies and inform decision-making processes. The AI tools used at The Springs, for example, have been really useful in identifying trends and streamlining workflows to improve outcomes and financial sustainability, Johnson said.
Roberts also stressed the significance of understanding data related to metrics such as star ratings and hospitalization rates to communicate effectively with providers, ensuring the best possible health outcomes for patients.
“AI helps us in looking at our five-star ratings, our staffing ratings, rehospitalization measures, or even seeing the most common diagnoses, to make sure that we have the services and the correct professionals within the facility to provide care and treatment for any niche type diagnosis,” Roberts said.
And, leveraging technology for regular communication and staff training, including through centralized platforms to disseminate updates, has ensured compliance across facilities and proven to be useful at Covenant Living, McLaren said.
“I was really surprised at how many of our communities, at a weekly Medicare meeting, were always talking about traditional Medicare,” she said. “They weren’t discussing Medicare Advantage or managed care. We were missing a huge component of managing this process within our organization because we weren’t discussing those residents and managed care Medicare payments on a weekly basis.”
Companies featured in this article:
Covenant Living Communities and Services, Creative Solutions in Healthcare, The Springs of Arkansas
