How to Address the Medicare Advantage Shift

Medicare Advantage (MA) has become a dominant force in health care. For home health, hospice and palliative care organizations, adapting to its rapid growth isn’t optional—it’s essential. MA enrollment is projected to reach 60% of the eligible population by the end of the decade and currently accounts for more than half of total federal Medicare spending. Additionally, forecasting shows that more and more Centers for Medicare & Medicaid (CMS) programs are going to go the managed population route. 

Business leaders need to be skilled and thoughtful about how they’re approaching Medicare Advantage. Here’s how organizations can prepare:

1. Start at the beginning: Sharpen intake functions to equip your organization for first-pass pay rate.

Not unlike any other revenue cycle reimbursement program, MA success begins with sharp preservice activities. That’s everything from understanding reimbursement policies and contracts to nailing the preservice activities around eligibility and prior authorizations. 

Since preservice activities contribute to roughly 60% of data on a claim form, this is an important and impactful area to focus on. Getting this part right at the beginning gives you a head start with timely reimbursement. At the end of the day, strong intake processes are cost-efficient. 

As the value-based landscape continues to take root, it’s important to optimize revenue cycle workflows to achieve cost-efficiency and be able to spend as much time as possible on providing care.

2. Use preservice activities as an opportunity to support a better patient experience.  

While it’s not commonly talked about in value-based care, preservice functions play a role in access to care and coordination of care. Home health, hospice and palliative care organizations are feeling the labor crunch, and demand for these services is only going to grow as generations continue to age. Conducting thorough eligibility verification up front helps patients receive the appropriate services covered by their plan. In doing so, access to care is improved and administrative delays are reduced. 

Having well-structured and streamlined eligibility workflows that align with the patient’s plan of care is incredibly important. In regard to care coordination, there’s no doubt that eligibility and authorizations play a role. Timely and complete access to clinical treatment documentation helps providers efficiently complete authorizations and develop an effective care plan for patients transitioning through the system. The bottom line is this: It’s a better patient experience when we’re efficient with eligibility and prior authorizations.

3. Capture the full picture of care through accurate coding.

Risk-adjusted models like MA rely on precise coding to facilitate accurate reimbursement, maintain regulatory compliance and influence quality measures. The result of accurate coding is capturing all diagnoses and reflecting the entirety of a patient’s care needs. Inaccurate documentation ultimately impacts reimbursement outcomes. As far as compliance goes, MA plans are subjected to rigorous oversight to prevent fraud, waste and abuse. Inaccurate or incomplete coding can lead to audits or penalties—and, in some situations, legal consequences. 

Finally, accurate coding is a key driver of quality scores such as Healthcare Effectiveness Data and Information Set and Star Ratings. Those ratings drive incentives and bonuses. Regardless of MA plans, accurate coding drives so much of the treatment that it’s important for it to be done accurately, efficiently and in a complete manner.

4. Have a plan in place to manage existing denials, but don’t lose sight of denial prevention.

Measurement is what will ultimately allow you to move from a denials management to a denials prevention mindset. Just like there are “never events” in the clinical space, the Netsmart revenue cycle team has a set of “never event” denials. Every revenue cycle team should identify their “never event” denials and have a plan for preventing them. Being able to categorize and segment denials is key to knowing which ones you want to prevent. 

This level of measurement also provides insight into needed process adjustments and highlights which denials require additional focus. For context, hitting a denial adds roughly 30 days to your reimbursement cycle (and that’s if you’re addressing them in the first four days of receipt). A strong denials prevention plan backed by data can help you avoid long, inefficient reimbursement cycles.

5. Embrace AI & automation to drive success with MA reimbursement.

There’s a lot of talk (and adoption) of artificial intelligence (AI) and automation. Each previously mentioned revenue cycle function that drives MA success can be sharpened with automation.

As mentioned earlier, data from preservice functions like eligibility and prior authorizations make up 60% of the data on a claim form. How could your organization benefit from using automation to verify eligibility and work authorizations? Fewer manual touches mitigate the risk of error and can certainly help drive down denials while equipping organizations for a higher first-pass pay rate. 

Coding is a popular topic that comes up when discussing where automation can help. While the human touch in this function is important—and it is unlikely to become fully automated—automation can help drive complete coding, provide auditing functions and do various optical character recognition (OCR) searches across documentation. The overall goal is to provide a coach, not a crutch, to coders. 

When it comes to denials, OCR and natural language processing (NLP) can pull in the various formats that denials come in and segment them. By segmenting denials, you can identify the “never event” denials that you want to reengineer from a process standpoint. Being able to categorize and queue denials for staff means you can get through them in a timely fashion and work toward preventing lost reimbursement. 

Automation-driven technology will be key for health care provider organizations to keep pace with change in the evolving health care landscape, including Medicare Advantage. While it may feel overwhelming at times, the potential to simplify reimbursement, support staff and optimize processes can transform the health care experience.