As home health care companies continue to take on more managed care patients, dealing with the delivery and payment system has been presented as both an opportunity and a significant challenge. Some home health providers in certain states are experiencing trouble getting reimbursed for services due to the current environment, costing them millions of dollars and years of administrative delays.
And the expansion of managed care plans, which contract with health providers and medical facilities to provide care at reduced costs to Medicaid beneficiaries, is likely to continue.
For one, Ohio Governor John Kasich recently proposed switching the entire state over to managed care, moving more than 150,000 mostly elderly and disabled Ohioans onto the plans that would provide long-term care services at home or in nursing facilities, The Columbus Dispatch reported. A number of home health companies, including Amedisys (Nasdaq: AMED), see managed care as a primary focus area this year.
One of the nation’s largest home health care providers, Almost Family (Nasdaq: AFAM), is working on solutions, including advocating for several bills through a state-by-state approach to ease the burdens of managed care.
Claims and Appeals Confusion
More than half of all Medicaid beneficiaries receive care from managed care organizations (MCOs) that contract with state Medicaid programs to provide services to beneficiaries. One of the biggest problems with managed care has to do with the claims and appeals process for home health care providers and caregivers in some states.
Specifically, some caregivers and providers run into trouble when claims are not accepted, for one reason or another. In some cases, there is no clear guidance on why claims are not accepted, and the appeals process is often on a short timeline that is difficult to comply with, according to Denis Fleming, Jr., vice president of government relations at Almost Family. Louisville-based Almost Family operates 340 branches in 26 states, including several with managed care services.
“Managed care, in our judgment, provides a vital service,” Fleming told HHCN. “We’re always looking to partner with managed care, but [the industry] is experiencing much greater delays in payment. The main problem is conflicting or no advice on how to submit claims, which often results in endless cycles of resubmissions and coding changes that can go on for months or years.”
Working with state representatives in Tennessee, Almost Family has helped put together legislation that amends existing managed care regulations in the state: The HMO Transparency in Claims Processing Act of 2017.
“We think it’s reasonable to put guardrails on processes to coincide with the payment cycle,” Fleming said of Almost Family’s efforts. “We think it’s a reasonable approach to work with home health on the front end of claims disputes, have a contact to work with home health, and have provisions that require clear guidance on reasons for claims denial.”
Clearing Up the Process
The legislation would ensure that Health Maintenance Organizations (HMOs)—which are a type of MCO involved in TennCare, the Medicaid program of Tennessee—clear up the process in a few ways. Three insurers provide plans through TennCare: UnitedHealthcare, BlueCross, and Wellpoint subsidiary Amerigroup.
“We have heard repeatedly from constituents about lengthy delays in HMO claims payment and nonpayment for vital medical services,” Representative Judd Matheny and Senator Janice Bowling of Tennessee, lead sponsors of the legislation, said in a statement. “Providers say they receive conflicting guidance from HMOs and hard to understand reasons for claims denial. Some hear nothing from HMOs for months and [receive] no payment for years despite efforts to submit and re-submit claims.”
And the slow and sometimes confusing appeals process in Tennessee isn’t minor; it’s costing some home care providers millions of dollars as they await payment for services already rendered. In some cases, these services provide long-term care services to disabled children at home.
“At least one constituent of mine has not received payment on some claims for over three years on millions of dollars in rural areas rendered [to] vulnerable children, mostly in rural areas with chronic conditions,” Rep. Matheny said.
The legislation aims to tackle this problem by requiring HMOs to follow its four provisions:
1. Designate an informed contact for interaction on the front-end of claims processing
2. Issue clear and timely responses to caregivers when claims are denied
3. Maintain an online portal for appeals and display claims status
4. Establish procedures to ensure claims are not denied arbitrarily when patient conditions are unchanged or when claims are re-submited by request outside timely filing deadlines
Almost Family is also taking this approach to other states, including Kentucky, Wisconsin and Connecticut.
“As state budgets become tighter with limited federal funds for Medicaid, you may see states look more at expanding managed care further,” Fleming said. “That’s why we’re trying to take the lead with some of our state-level strategies to prepare for the future and give ourselves a level playing field.”
Written by Amy Baxter
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