Home Health & Hospice Week

Protect yourself from denied reimbursement with some upfront work.

Under the new Part D drug benefit and rise of Medicare managed care, providers must be more careful than ever to secure their rightful reimbursement.

Knowing whether your patients are under a Medicare Advantage plan that restricts home care utilization can be key to avoiding throwing away hundreds if not thousands of dollars per patient. Experts offer this advice to manage your managed care patients:

1. Check the Common Working File. Before you admit a patient or provide services for a patient you suspect has elected an MA plan, check the CWF to verify eligibility, the National Association for Home Care & Hospice advises its members. Then continue to check CWF status as frequently as possible to make sure you aren't taken by surprise.

"Agencies cannot afford to learn weeks or months later that patients were managed care, not fee-for-service," maintains Burtonsville, MD-based health care attorney Elizabeth Hogue. "If they do not have a contract with the patient's managed Medicare plan, they will not be paid for services they rendered."

2. Continue investigating. If you have a patient who is likely to have switched to managed care--for instance, a dual eligible--continue searching for their Medicare status, NAHC advises. That means asking patients and family members themselves, as well as other providers serving the patient.

3. Contact drug plans, Medicaid. You can also ask the MA or Special Needs Plans directly if they are enrolling your patients--either passively or actively, notes the Council of State Home Care & Hospice Associations. If you find out the patient has elected the SNP, be sure to find out if they also accepted a full plan switching them from fee-for-service to managed care.

You can seek patient information from your state Medicaid program as well, NAHC notes.

4. Keep patient communication open. "Make it a focus of your staff" to request that dual eligible patients tell you immediately "if they enroll 'completely' in one of these plans," the Council urges.

"Inform patients of their responsibilities to notify your agency of any changes in enrollment status and the consequences of receiving care from your agency while enrolled in a managed care organization," NAHC adds.

You may want to hand out a notice to beneficiaries summarizing the changes and urging them to keep you informed, suggests consultant Alison Cherney with Brentwood, TN-based Cherney & Associates. The handout can inform beneficiaries of how to opt out of SNP full plans, the Council says.

5. Consider diversifying into managed care. Now may be the time to consider a leap into the managed care market if you haven't yet, Cherney suggests. Or if you already do managed care business, contact the SNPs and MA plans and try to get on as a participating provider.

If the Medicare managed care market continues to grow, now is the opportune time to get into the system. If plans "end up capturing a substantial portion of traditional Medicare patients... it would behoove every Medicare HHA to contact them early on and try to get signed up as an approved provider," the Council urges.

6. Report violations to authorities. There are restrictions on how Medicare managed care plans can market their services and administer the benefit, Hogue points out. If you see plans that engage in prohibited marketing practices like door-to-door solicitations or paying cash inducements, report the problems to CMS and proper state authorities.

Likewise, agencies can report inappropriate underutilization by plans to CMS, Hogue adds.