Skilled Nursing News: It may be an understatement, but today’s environment is challenging for SNFs. Why should managed care be a strategic priority?
Brian Deeley: We are all aware of the financial and operational challenges of Medicare Advantage (MA) versus Traditional Medicare. We work with thousands of SNFs across the country who are increasingly recognizing the importance of making managed care a strategic priority rather than just a “necessary evil.” For starters, the sheer quantity of individuals enrolled in Medicare Advantage means that MCOs and SNFs are going to have to find ways to constructively work together. The MA population in the US has grown by 121% over the last decade, increasing from 14 million enrollees in 2013 to nearly 31 million in 2023. This surge not only reflects a fundamental transformation in the health care landscape but also underscores the compelling need for SNFs to “lean into” the discomfort and embrace managed care.
While we concede collaborating with managed care entities can often be challenging, we encourage providers to not limit their discussions by narrowly focusing on simply “getting a contract” and “negotiating for the highest rates possible”. Rather, there are numerous examples of SNFs and MCOs forging successful strategic partnerships centered around the triple aim of improving the experience of care, improving the health of populations, and reducing per capita costs of health care. In fact, MNS has worked with hundreds of SNFs across the country to engage more meaningfully with MCOs to explore novel reimbursement mechanisms. By ensuring both sides are aligned, MNS can create a “win-win” that allows SNFs to ultimately receive more attractive performance-based reimbursement. Ultimately, the SNFs that can make the strategic shift towards value-based care will have a competitive edge that positions them for long-term financial and operational viability.
What advice would you provide to SNF operators who want to partner closer with MCOs but who may be discouraged by the lack of responsiveness or engagement?
For MCOs, the process of contracting with SNFs generally falls within the realm of “Ancillary Services,” which really translates to an “All Other” bucket of services. This means the MCO contract managers whom SNFs are reaching out to are often juggling a diverse spectrum of health care providers, encompassing services such as Durable Medical Equipment (DME), Home Health, Dialysis, Laboratory services, and more. It can be frustrating for SNFs who may not get the level of responsiveness they expect; however, the constraints on the MCO staff are precisely why many MCOs turn to organizations like MNS for additional support and expertise in strengthening their SNF networks. This collaboration may involve the negotiation of contracts in new or expanding markets or the transformation of outdated agreements into more adaptive and value-based reimbursement structures. The intricate challenges involved in forging these relationships with MCOs illustrate precisely why so many SNF providers nationwide rely on MNS to facilitate the acquisition of these contracts. MNS is among a select few organizations delegated by MCOs to manage SNF Credentialing. This authorization affords MNS a unique perspective and influential role with MCOs when they are evaluating adequacy requirements and contemplating expanding (or contracting) their SNF networks.
For SNFs that opt to “go it alone” in the quest to secure MCO contracts, they will need to be both proactive and transparent. Virtually all providers are keenly aware that they need to put their best foot forward to MCOs by highlighting their services and emphasizing the quality of care they provide. However, from the MCO vantage point, every SNF can appear to be touting similar capabilities, so it is important to present clear and persuasive data on patient outcomes and quality measures to help differentiate your facility(ies).
Demonstrating to an MCO that your organization is data-driven will not only help get you “a seat at the table,” but it can also serve as the basis for a performance-based arrangement. Showing an MCO your established baseline data sets the foundational basis for a discussion focused on how best to drive incremental improvement.
While not all MCOs are currently supporting value-based contracts with SNFs, virtually all of them are heading in that direction. Your willingness to share data is a helpful first step; but also, a willingness to “take a calculated risk,” by directly tying your reimbursement to the facility’s ability to drive improved outcomes and measures will speak volumes to even the most skeptical MCOs. This approach fosters alignment, encourages data transparency, and underscores the provider’s confidence in their facility’s ability to deliver positive outcomes. Ultimately, by demonstrating a willingness to enter an arrangement where financial incentives are in harmony with the delivery of superior care, providers send a strong message to MCOs, affirming their steadfast belief in their facility and staff’s capacity to deliver excellence.
When you say MNS is “delegated for credentialing” what does that entail, and could you provide some insight into the challenges SNFs face relative to credentialing and re-credentialing processes with MCOs?
SNFs are confronted with an array of credentialing challenges that significantly impact their operational efficiency and their capacity to deliver services effectively to members of MCOs. These challenges include navigating and adhering to the myriad of contractual requirements set forth by MCOs, which include providing accurate and timely documentation across a wide spectrum of operational areas as well as meeting numerous quality reporting and compliance criteria. The process of enrolling as a par provider can vary from each MCO which makes it an even more time-consuming and demanding administrative endeavor. Once a SNF is fully credentialed, they must stay vigilant and continuously stay abreast of new/changing re-credentialing requirements to ensure ongoing compliance.
The importance of effective communication and coordination between SNFs and MCOs cannot be overstated in the realm of credentialing. MCOs often possess distinct policies, procedures, and quality benchmarks that SNFs must both grasp and adhere to—a particularly arduous task when dealing with multiple MCOs across multiple facilities. It’s basic math, if you are responsible for credentialing 5 facilities that each have 12 MCO contracts that encompass 60 distinct relationships. If each MCO requires 10 distinct documents that is 600 items that need to be tracked, maintained and provided in a timely manner just to stay in network with those MCOs.
It is precisely that administrative nightmare that led MNS to develop CredentialPointe. Our SNF providers have always been very complimentary of our Credentialing support and many asked if they could license our software to enable their organization to keep better track of all the documentation and requirements.
CredentialPointe offers a comprehensive solution for optimizing the efficiency of credentialing processes. It streamlines these operations by automating tasks and addressing common challenges such as the misplacement of essential documents during staff turnover. Through this platform, providers can conveniently access and manage all their credentialing and re-credentialing documents in a secure centralized repository, irrespective of location.
The system also offers advanced features like auto-populating applications with supporting documents, reducing the risk of errors, and ensuring compliance; as well as dashboard alerts to keep users informed about document updates and expiration dates. SNFs all over the country were also asking if they could use the same secure document repository to house all their MCO contracts. In response, additional functionality was added to CredentialPointe to not only house all the payor agreements, but summaries of key contractual terms and rates/reimbursement structures are readily available to facility staff – access and security can be customized across large or small SNF organizations to ensure real-time and appropriate access based on each group’s roles and responsibilities. We’ve found that making contractual and rate information available more broadly helps our SNF partners capture more referrals and avoid any unpleasant surprises when accepting placements.
So, for SNFs that can get a contract and pass credentialing, the process of interacting with the MCO is just beginning. What advice do you have for SNFs for how to capitalize on referrals and what steps they can take to secure quicker authorizations? How can SNFs ensure timely reimbursement for high acuity and high-cost patients while balancing the pressure from hospitals and payors?
Facilitating quicker authorizations for SNFs requires a multifaceted approach. Thorough and accurate documentation, proactive communication with payors, and effective utilization review processes all form the foundation of expediting authorizations. Timely submission, consistent follow-up, and collaboration with medical directors of payors also play pivotal roles in securing quicker authorizations. Additionally, SNFs need to ensure they are receiving complete and timely clinical information from referring hospitals but also relaying complete and timely clinical information to MCOs. The process for obtaining authorizations is always subject to change as MCOs offload risk to third parties or launch new portal functionality so continuous monitoring and process evaluation is needed to help identify areas for improvement.
At MNS we work tirelessly with both our SNF providers and our MCO payors to find ways to enhance and expedite the authorization process. Expertise in payor processes, requirements, and meticulous preparation of authorization requests are hallmarks of such partnerships. Around-the-clock support for patient placements, benefit verifications, and authorizations eliminates time zone constraints and ensures prompt attention to a facility’s authorization needs.
One of the most significant advantages of such partnerships is the simplicity they bring to the admissions process. Instead of navigating numerous individual plans and portal logins, we provide these organizations with a single, accountable point of contact. Streamlining the process, eliminates confusion, and ultimately accelerates the authorization process; allowing SNFs to focus less on administrative processes and more on delivering quality care.
According to our VP of Clinical Operations, Voni Hope, SNFs often find themselves in a challenging position when it comes to taking in high-acuity and high-cost patients. Hospitals and payors may exert pressure on SNFs to accommodate such patients due to the growing demand for complex care services. While SNFs provide quality care, the financial aspect of this equation can be daunting. SNFs face the predicament of offering the necessary care without assurance of proper or timely reimbursement, which can significantly impact their financial stability.
This is where MNS steps in to alleviate the burden. MNS offers a comprehensive solution that not only streamlines the authorization process but also ensures that SNFs can secure timely reimbursement for the care they provide. By expertly managing cases, MNS can expedite the authorization process and facilitate timely reimbursement, especially for high-acuity and high-cost patients.
Additionally, MNS’s extensive knowledge about payor processes, requirements, and documentation needs means that SNFs can be confident in their claims for reimbursement. With the support of MNS, SNFs can navigate the complexities of managed care effectively and receive the financial compensation they deserve for delivering exceptional care to high-acuity patients. This partnership empowers SNFs to focus on their core mission of providing quality care, knowing that their financial interests are safeguarded.
Reimbursement from MCOs has historically fallen below the rates offered by Traditional Medicare. Aside from the performance-based reimbursement, what strategies can SNFs employ to secure equitable compensation for the comprehensive services they deliver to MCO members?
Navigating all the various clinical and administrative requirements to care for an MCO member only to receive incomplete or inadequate reimbursement is incredibly frustrating. However, it is even more disheartening to invest that same level of effort to meet these demands and ultimately receive no reimbursement at all. All it takes is one misstep and SNFs can find themselves having to write off significant amounts of revenues related to managed care stays. At MNS, we work closely with SNFs to guarantee that 100% of stays are appropriately authorized. We ensure that updates are meticulously and promptly provided to MCOs to eliminate any room for dispute when it comes time for claims to be settled.
Facility staff are generally focused on providing care so it’s a little unreasonable to ask those same individuals to have a full and comprehensive knowledge of each and every contract, including which uncommon prescriptions or services may not be covered. While getting sufficient reimbursement starts with securing equitable contracts, it is equally crucial for every member within a facility to have visibility into these contracts, particularly in relation to their respective functions. As mentioned previously, one feature of MNS’ proprietary CredentialPointe application is the provision of secure online storage for each facility’s contracts. Moreover, it offers around-the-clock access to critical contract details, allowing employees to retrieve necessary information swiftly and effortlessly, guided by the unique user permissions and profiles that you establish.
Identifying high-cost medications or contractual carveouts at the time of admission represents only half of the challenge. SNFs must ensure seamless integration with their billing teams to guarantee that these additional services are accurately billed and collected. It is regrettable that, on occasion, we observe SNFs that have heightened their awareness of their managed care contracts but fail to bill for the services they diligently negotiated and secured during the initial stages.
At the critical juncture of payments, what innovative approaches or tools can SNFs employ to streamline and expedite the processing and payment of claims?
Cash conversion is key and ensuring quicker payment of claims for SNFs involves a comprehensive strategy. It begins with thorough and accurate claims documentation, proactive communication with payors, and effective utilization review processes. These components form the foundation for expediting claims processing. Collaborating with payors to understand their specific requirements and procedures is crucial for streamlining the payment process. Additionally, staying informed about industry changes, regulatory updates, and market trends that may impact claims processing is essential.
According to Jennifer Little, our Director of Reimbursement, partnering with organizations like MNS who are experienced in claims management, can significantly expedite the payment process for SNFs. The sheer volume of cases and claims that MNS handles across broad geographies allows us to identify nonpayment trends and patterns with various MCOs as they are occurring, providing an invaluable opportunity to be proactive (not reactive) in rectifying payment system failures and swiftly addressing/correcting underlying issues.
Moreover, MNS often offers a single, accountable point of contact for claims management, simplifying the process and eliminating confusion. This efficient approach ultimately accelerates the claims payment process, allowing SNFs to maintain financial stability and focus on providing quality care.
In a couple of words, finish this sentence: “In 2023, the skilled nursing industry has been defined by…”
… a continued focus on optimizing efficiency, quality of care, and effective managed care management. SNFs are continually being asked to “do more with less”, whether it be staffing, resources, or reimbursement. Organizations like MNS have played a pivotal role in supporting SNFs in continually streamlining their operations and serving as an extender of their staff to facilitate securing contracts, obtaining timely authorizations, and expediting processes from admissions through receipt of payment. This year has seen an increased emphasis on leveraging technology and expert support to ensure that SNFs can deliver high-quality patient care while navigating the ever-evolving health care landscape with confidence.
What advice would you offer to a SNF in negotiating a Managed Care Contract?
To navigate the intricacies of managed care contract negotiations effectively, several key strategies should be kept in mind. Firstly, understanding the managed care enrollment of your patient population and identifying the most beneficial payors in your region is pivotal. Armed with this knowledge, you can make informed decisions during the negotiation process. When delving into negotiations, it’s vital to approach the process strategically. This includes recognizing the value of your facility, the range and quality of care services it provides, and emphasizing these strengths to the payor.
From the MCO vantage point, every SNF is touting similar capabilities, so it is important to present clear and persuasive data on patient outcomes and quality measures to help differentiate your facility(ies). In addition, thoroughly reviewing the contract’s terms, with a focus on reimbursement rates, covered services, and network status, is essential. Building positive relationships with payor representatives, remaining flexible, and staying informed about industry changes all contribute to a successful negotiation. Finally, emphasizing patient-centered care, along with a commitment to high-quality outcomes, can be a compelling point in your favor. Remember that a comprehensive and well-prepared approach is key to achieving a favorable and sustainable managed care contract.
Editor’s note: This interview has been edited for length and clarity.