Medicare Compliance & Reimbursement

Home health agencies battling managed care tactics probably aren't going to see relief any time soon, said two managed care experts at the National Association for Home Care & Hospice's March on Washington conference this month.

As long as the Medicare program continues to pay Medicare Advantage plans at the same or better levels, there will continue to be many plans in the market, attorney Vicki Gottlich with the Center for Medicare Advocacy predicted in an April 7 conference session, "The Future of Private Plans Under the Medicare Program."

The number of plans in the future will depend on the payment rates and the administrative requirements, managed care expert Marsha Gold with the Mathematica Policy Research think tank forecasted in the session.

That wasn't what the room full of frustrated home care providers hoped to hear. HHA representatives presented a laundry list of problems they deal with every day from Medicare managed care plans.

"We all have more things to worry about ... (like) taking care of patients," said conference attendee Norma Goodman, owner and administrator of Infinity Health Services in Cleveland, OH.

Professional Healthcare Resources has trouble finding out even basic payment information from managed care plans, said Doug Smith of the Annandale, VA-based agency with eight locations. For instance, whether the plan pays for home care by visit or by episode.

A Massachusetts provider complained about plans' increasingly restrictive coverage. For example, two major plans will approve just three visits for an elderly patient with complex care needs, which is "very disappointing and alarming," the rep noted.

Congressional solution: "I think this is really cost cutting," Gottlich said. The Center is hearing about similar restrictions in a number of states. HHAs will probably have to turn to their members of Congress for relief from such problems, she suggested.

But providers aren't likely to see any legislative action on the matter in this election year, she added. Home care organizations should probably aim for a lobbying push about managed care issues in 2009, once a new president is in place.

One change Erik Drennan with Mays Home Care would like to see is a 30-day waiting period before a patient's switch to Medicare Advantage takes effect.

That way agencies would have a better shot at actually finding out about the enrollment before furnishing or billing services, said Drennan with the agency that operates in Oklahoma and Texas.

Another problem facing agencies involves quality improvement organization appeals, said Laurie Neander with At Home Care in Oneonta, NY. A QIO appeal of a managed care coverage decisions requires "reams of paperwork" from the provider but little effort from the MA plan, she maintained.

"It's a huge problem not just for us but for patients," Neander said. A QIO may repeatedly overturn an MA plan's coverage restrictions, but the plan can just go on making the same limitations with little consequence.

Other problems conference attendees bemoaned included payment delaying tactics and significantly higher administrative costs for managed care patients, due to plans' extensive documentation requirements.

Expansion ahead: Not only are MA plans here to stay until the reimbursement or regulatory environment changes, they are likely to expand, Gold and Gottlich informed agencies. That's because private employers are now opting to use MA plans for their retiree benefits.

Under such arrangements, retirees must stay in the private fee for service MA plan chosen or give up their retiree health benefits, Gottlich explained.

Managed care has a big interest in capturing business from these employer groups, Gold observed.

Some major groups, such as state governments and companies like John Deere, already have opted for PFFS participation for retirees.

Except for the retiree situation, regular Medicare beneficiaries can avoid the access and payment problems associated with MA plans by simply not enrolling in a managed care plan and staying on regular fee for service Medicare.

But many benes are lured by the "free" benefits plans offer, which are attractive to seniors just reaching Medicare age who are relatively healthy, Gottlich noted. Those benefits include vision care and glasses, dental care, no or reduced coinsurance and deductibles, and health club memberships.

Most beneficiaries don't realize that they'll end up paying more out of pocket if they run into more complicated health problems under a PFFS plan.

Out-of-pocket expenses run $81 on average for healthy beneficiaries and $2,254 for benes with chronic needs in PFFS plans, Gold said. That compares to a $72/$1,487 figure for Medicare HMOs.

The Government Accountability Office noted such higher costs for some beneficiaries in a recent report. One plan the GAO looked at had a $30 copay for home care visits, Gottlich pointed out. Another charged beneficiaries $75 to see a specialist.

Confusion reigns: Medicare beneficiaries now have so many different plan options that they've become "a meaningless choice," Gottlich maintained. The aged and disabled have more confusing choices than younger people in the workforce, Gold agreed.

Beneficiaries who find out their MA plans aren't benefiting them are generally locked into them for a year, Gottlich noted. Or, as many home care providers have seen, benes don't even understand when they've been enrolled in MA. They aren't helped by the new trend of plans calling their products "Medicare replacement insurance," she added.

Medicare requiring beneficiaries to enroll in a Part D plan for prescription drug coverage just increases that confusion, Gottlich noted.

And managed care plans aren't helping benes to figure it out. They've been slammed in congressional hearings for false and deceptive marketing practices, including giving clients incorrect information on coverage.

Even Centers for Medicare & Medicaid Services-approved advertisements increase confusion by failing to distinguish between different plan options offered by the same company, focusing on the freebies instead of potential increased costs, and omitting network and cost-sharing information that may not be desirable, Gottlich argued.

"We are up against a misinformation campaign that is supported by a lot of money," Gottlich lamented.