Medicare Compliance & Reimbursement

In the recent Medicare Improvements for Patients and Providers Act, Congress addressed more than just competitive bidding, therapy caps and Medicare reimbursement.

The MIPPA legislation set some strict standards for Medicare Advantage plans too, and the outcomes could work both for -- and against -- home health agencies.

If your agency is used to being schmoozed by MA plans with free lunches, non-related health products and the like, that's about to change. According to Section 103 of MIPPA, effective for the 2010 plan year, MA plans will have limits on these types of sales activities, as well as on co-branding and commissions. In addition, MIPPA holds MA plans accountable to state appointment laws affecting agents and brokers, reports a notice from the National Association of Home Care & Hospice.

The good news: Although some MA plans understand the value of home health and pay fair rates, the new requirements will help address bad plans and overly aggressive sales people who provide dishonest marketing, points out Bob Wardwell, vice president of regulatory and public affairs for the Visiting Nurse Associations of America.

Congress' decision to "go after" MA plans also helped finance the Medicare Physician Fee Schedule payment fix, adds William Dombi, vice president of law for NAHC. "And that meant less risk of home health suffering a reduction in its annual inflation update."

The bad news: You may see an impact on the negotiation of payment rates between the MA plans and the providers, Dombi notes. "If plans are getting less money, they may be willing to pay less money -- but that's going to be up to the home care agencies to decide the stance they'll take in negotiations and when to say no to a particular contract."

If Private Fee-For-Service plans still want to participate in Medicare Advantage, they'll have to play by some new rules. Beginning in 2011, these plans will have to measure and report on their providers' quality of care. But the kicker is that they'll also have to form provider networks with contracts.

Details: In counties where there are two or more non-PFFS plans, PFFS plans will no longer be able to simply "deem" providers into the plan without a contract. Under current law, PFFS plans don't have to prove they can meet access standards if they allow any willing qualified Medicare provider to participate, and they pay as tradi-tional Medicare would pay.

One argument is that the network requirement would provide better access to care because there would be contracts between the providers of services and the plan. On the other hand, "private FFS plans may limit the number of providers who are eligible to participate," creating poorer access to care, Dombi says. And don't forget that some provider types may not even be willing to participate, he adds.

Other downsides: In addition to seeing an impact on MA payment rates, agencies may see PFFS plans move away from an episodic payment approach that's equivalent to traditional Medicare, Dombi continues.

Not to mention, from the beneficiary's view, the networking requirement could restrict free choice of providers, Wardwell points out.

Silver lining: All that said, the networking requirement could also discourage poor MA plans from entering the field purely for high profits, Wardwell says, and that's a good thing.