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What you should know about Medicare managed care
By Elizabeth E. Hogue, Esq., Burtonsville, MD
Managed Medicare plans recently got a "shot in the arm" in the form of significant increases in rates they are paid. These rate increases have encouraged them to once again seek to enroll more Medicare beneficiaries.
In addition, managed Medicare plans have stepped up their marketing efforts in conjunction with the availability of prescription drug coverage. They are, for example, "cross selling" managed Medicare plans in conjunction with the prescription drug benefit.
These developments can spell trouble for providers. They may, for example, have difficulty determining whether patients are fee for service or managed Medicare upon admission. In addition, patients who already are admitted to agencies may enroll in a managed Medicare plan without telling providers. Agencies may be unable to bill for services provided after enrollment and may be unable to convince managed Medicare plans that they should pay for services provided after enrollment.
While it remains unclear whether the efforts of managed Medicare plans to increase enrollment will succeed, there are practical steps that agencies need to take meanwhile in view of these developments. These steps include:
(1) Agency personnel must verify the status of Medicare patients as either fee for service or managed care preferably before admission and on a regular, periodic basis thereafter. Agencies cannot afford to learn weeks or months later that patients were managed care, not fee for services, and that, if they do not have a contract with the patient's managed Medicare plan, they will not be paid for services they rendered.
(2) Agency staff members need to be alert for problems in marketing Medicare managed care plans. There are limitations on the marketing activities of managed Medicare plans. The following activities are, for example, prohibited:
- Door-to-door solicitation prior to receiving an invitation to a beneficiary's home.
- Requests for personal information such as social security numbers and bank account numbers.
- Paying cash inducements to beneficiaries to sign up or providing cash gifts to encourage beneficiaries to sign on.
- Providing inaccurate or misleading information during sales presentations.
Violations of the rules should be reported to both the Managed Care Group at the Centers for Medicare and Medicaid Services (CMS) and the insurance commissioner in the state in which the inappropriate marketing activities occurred.
(3) Agency staff members should also be alert for problems with access to home health services. Managed Medicare plans are required to provide home health services. But they may say that the agencies currently serving patients cannot continue providing services after patients enroll in their plans because the plans have their own home health agencies or have a limited number of preferred providers of home health services. In at least one instance, the managed Medicare plan did not have a certificate of need (CON) to provide services in the county in which the patient resided. Problems with access to home health services should also be reported to CMS.
(4) In addition, agency personnel should try to identify and document problems with utilization of home health services. Beneficiaries who enroll in managed Medicare plans are entitled to at least the same home health services they would receive if they remained fee-for-service patients.
Since managed Medicare plans are paid a fee per member per month, there are incentives to skimp on care. As soon as beneficiaries enroll, managed Medicare plans may reduce their services significantly or perhaps altogether.
The classic example occurs when patients are receiving home health services from an agency when they enroll in a managed Medicare plan. The home health agency was providing skilled nursing services, home health aides and therapies. The home health agency had no denials for care rendered. There was no significant change in the patient's condition after enrollment. Yet the managed Medicare plan reduces services or discontinues them altogether.
Again, problems with underutilization, a form of fraud and abuse, should be reported to CMS.
Medicare beneficiaries have "voted with their feet" in the past and have not enrolled in managed care plans in the numbers that were originally anticipated. It remains to be seen whether current strategies will influence patients to enroll In the meanwhile, agencies should be vigilant about the issues described above.
[To obtain a copy of a book entitled Managed Care Contracting, send a check for $30.00 that includes shipping and handling made out to Elizabeth E. Hogue, Esq., 15118 Liberty Grove, Burtonsville, MD 20866. Phone: (301) 421-0143. Fax (301) 421-1699. E-mail: [email protected].]
Managed Medicare plans recently got a "shot in the arm" in the form of significant increases in rates they are paid. These rate increases have encouraged them to once again seek to enroll more Medicare beneficiaries.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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