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How to handle common Medicare Advantage RCM challenges

The popularity of Medicare Advantage (MA) plans continues to grow, and the number of different plans being offered from payors is also increasing. But managing RCM for MA plans is challenging, because there’s no consistency in the plans and a multitude of variables. This complex environment means that it’s essential for home health and hospice agencies to adapt and learn how to handle these common billing and coding challenges and to keep an eye on what’s coming next.

Here are common challenges you may encounter, some tips for handling them, and ideas for staying ahead of MA changes.

Timely filing: If you’re contracted with a payor who offers MA plans, they control timely filing. Don’t assume timelines are the same as for Medicare. For example, an MA plan may say you have to bill your claim within 120 days. It’s 365 days for Medicare. MA plans are all over the place with timely filing deadlines. Agencies may assume MA plans align with Medicare’s filing rules, but that isn’t always the case.

Paying per visit or per episode: The way MA plans pay isn’t necessarily like Medicare. You may think a patient’s plan has a contracted rate (requiring episodic billing), but the plan actually pays per visit. MA plans differ in how they pay and it’s important to be knowledgeable about the specifics of each.

Claims coding: Inconsistent billing requirements and claims processing are plentiful across the different MA payors. This makes it tough for agencies to track down and resolve issues that result in unpaid claims and reduced payments. In addition, if you’re not coding specifically enough, you may trigger a medical records review, which can be time-consuming and delay your agency’s reimbursement.

Notice of admission (NOA): Beginning last year, original Medicare guidelines required home health agencies to submit NOA within five days from the start of care. But private MA payors provided no such direction, leaving many agencies struggling to obtain final payment when NOAs weren’t in place within the five-day rule. It’s important to review contracts and know which payors require this notice. When it is required, be sure it’s provided within five days of referral or intake to ensure you’re meeting all requirements.

General observations about working with MA plans

The larger the MA payor is, generally the more difficult it is to deal with them. These large payors tend to have a lot of medical records reviews. In these instances, they might pay ahead, or they may wait until the review is complete, which holds up your payment. If they do this frequently and you have a high census or you’re short-staffed, it can create a multitude of hardships. Having to turn over a lot of records in a short amount of time with an already short-staffed and overworked team can be very demanding and unsustainable.

Another common misunderstanding arises when a hospice patient moves back to home health during the same month. Do you bill hospice for the rest of the month then transition to MA? It’s important to know who and when to bill and to remember that MA has many segments. Always remember, MA plans are not the same as Medicare — be careful and thorough when handling the coding and billing for these plans to protect your agency’s bottom line.

Getting ahead of MA changes

MA plans can change at any time, but open enrollment is when most changes surface; enrollment is in November and December, and changes take effect in January. Even if you don’t check for changes monthly, you definitely should check during this time period because it can be time consuming for common working files to update. It’s crucial to talk to your patients and consistently run your eligibilities.

We recommend developing a checklist to prepare for MA changes, or changes when patients move from Medicare to MA, that includes specific things to watch for. We also encourage you to talk with your patients to gauge their understanding of their existing coverage and any upcoming changes they’re aware of. Usually, January and February billing cycles are when you have the highest rate of claims denied, because patients may have switched from Medicare to MA.

It’s also helpful to know who your provider representative is so you have a direct contact for issues such as incorrect payments, excessive medical record review, or non-payment for authorized care. The bigger your agency, the more important this is, but small agencies can also benefit from having a good relationship with provider reps.

Get help from the experts

Because MA plans are all different, and often change, it can be a challenge to effectively code and bill for maximum reimbursement. If you’re thinking about getting help to keep up with all the nuance and change, or to ease your team’s workload by outsourcing this work, our team of experts is ready to put their knowledge to work for you.

Get a handle on Medicare Advantage with help from the experts.

See what MatrixCare can do for you

Sue Weeks

Sue possesses a diverse range of experience in the Home Health and Hospice field, including firsthand involvement in managing authorizations, accounts receivable, and various other revenue cycle positions within Home Care and Hospice agencies. Additionally, she has played a pivotal role in software implementation, specifically in the financial model, where she trained customers on best practices, software functionality, and system administration. Sue's experience includes working closely with payors, particularly Medicare, and she has become a subject matter expert on the specific billing rules and regulations applicable to Home Care and Hospice.

Currently serving as the Project Manager for the Revenue Cycle Division, Sue leverages her skills and knowledge to develop optimal workflows for the RCM team, update auditing and quality measures, provide training, and collaborate with customers to enhance their billing and accounts receivable processes.

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