Medicare Compliance & Reimbursement

Plan for these hurdles in advance to assure success

A growing number of governors - such as Georgia Gov. Sonny Perdue (R) and Florida Gov. Jeb Bush (R) - are looking to managed care plans to save their Medicaid programs. That doesn't mean it'll be an easy job for health plans. Here's what to look for:

1. Tough population. "Medicaid populations frequently have different needs than the commercial populations," says Jim Verdier of Mathematica Policy Research Institute. In Medicaid, a higher proportion of the more costly population is pregnant. Some of the young children can be fairly expensive as well. And if a state includes the disabled population in its managed care program, that's a very different patient group than commercial plans are used to dealing with.

2. Provider scarcity. In urban and very rural areas, it can be a challenge to find physicians who will treat Medicaid patients, explains Anthony Horball, CEO of Ion Health Holdings Inc., a Medicaid plan based in Erie, PA. Doctors like to live in the suburbs. "It's hard to get doctors to work in the 'hood," Horball says, "and it's also hard to get them to work in the forest."

It's also difficult to find an adequate network of dentists, Horball says, for states that include a dental benefit.

3. Reporting requirements. The Medicaid program has some significant requirements for collecting and submitting to the states data that can be used for quality monitoring and management purposes, Verdier says. That is somewhat unique to Medicaid, so plans that specialize in Medicaid are better able to meet the requirements than commercial plans are, giving them "a considerable advantage," he warns.