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 How to Survive the Managed Care Conundrum

Sean Mockbee
Sean Mockbee, executive director of assisted living community Sunshine Village in Phoenix, is well-accustomed to Medicaid managed care, as Arizona has long been under such a system. So, it makes sense to ask him what other assisted living and long term/post-acute care providers should know about managed care and how best to handle interactions with managed care organizations (MCOs).
 
The MCOs, which are the private health plans a state contracts with to manage all or some of its Medicaid beneficiaries, may take some getting used to, he says, and thus require training of staff on how to deal with bread-and-butter issues like claims processing.
 
“There’s plenty of claim denials for whatever reason, so you have to be ready to resubmit,” Mockbee says. “This means the business office director plays a bigger role in facilities than they used to. And then for me I think the executive director role is different. You still have to manage your families and staff and all of that,” he says, “but you [also] really have to look at the perception of the managed care plan.”
 
In that way, an assisted living or other long term care provider can become valuable to the MCO, and become a type of preferred provider in its network.
 
“If you have bad outcomes or if something doesn’t go right, they may quit referring to you. Well, they’re the biggest
referrals for us in the state. You know if you tick them off they don’t send you the people. Your referrals drop,” he says. “You really have to manage the relationships with the plans, making sure your staff are working with the case manager.”
 
It is this basic relationship with the MCO via its case managers that can make or break business dealings, and it comes down to making sure that all the information the MCO needs is there to ensure smooth interaction between payer and provider.

Tackling Prior Authorizations

As for advice on what can be a dreaded problem of prior authorizations, resulting in payment delays or nonpayments, Mockbee says, take the time to make sure staff are on top of the issues.

“Those prior authorizations are very important because claims can be rejected if the authorization has a different code, be it a diagnosis code or a billing code, they call them billing modifiers here. Just anything,” he says.

There could also be problems in billing generated by having the wrong dates for hospital stays. If a resident goes to the hospital, for instance, an assisted living community cannot bill the MCO for the duration of that admission. Once the MCO payment stops, the provider must resubmit for revised payment authorization that reflects the correct dates, he says.

Quality in Play

How do providers show their quality programs work? Mockbee says his community monitors hospitalizations like a skilled nursing facility (SNF), “just like you’re hearing about it nationally,” he says. “At the end of the year, I report my numbers to the health plans about what my percentages are. We focus on reducing psychotic medications for instance … kind of the same quality measures as the SNFs. We kind of mimic them because it helps us tell our story.”

A share of the time spent on reporting data to the MCOs is intended to dispel the myths about what assisted living is all about in 2017. “In assisted living typically, historically I guess, it was about the saying, ‘when in doubt, send them out.’ They don’t have the staff, they don’t have the nursing capabilities, send them to the hospital,” Mockbee says.

“Well, if you’re spending that plan’s money [by sending them to the hospital], it affects the rates you receive. Plus, they monitor what assisted living hospitalizations and rehospitalizations are. They know which [communities] are sending people out more than others.

“If you want to keep the referrals coming,” he says, “you need to keep taking care of those people. Yes, the family has to be happy and the residents happy, but this is also about having the data-driven proof that we’re saving MCOs money by having them here versus somewhere else.”
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