Participants should be aware of the following financial/non-financial relationships:
Maureen McCarthy, RN, BS, RAC-MT, QCP-MT, DNS-MT, RAC-MTA: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Managed Care Plans, also referred to as HMOs or PPOs, include equivalent coverage to traditional Medicare Part A and Part B, and tout additional benefits like routine vision, hearing and dental services and prescription drug coverage. Plans have become increasingly desirable due to these added benefits and CMS encourages beneficiaries to enroll in Managed Care plans.
Currently, Managed Care has consumed 30% of the Medicare population and is anticipated to grow exponentially through 2030. With this increase of enrolled beneficiaries, Managed Care insurers continue to find new reasons to deny payments to long term care providers. Managed Care plan administrators must agree the beneficiary’s treatment is medically necessary, or they may deny approval for service. Further, HMO plans have limited appeal rights. Skilled nursing facilities are seeing reduced reimbursement year-over-year with commercial insurers managing Medicare and Medicaid programs.
This session will provide key strategies to manage Managed Care. Attendees will examine the differences between Managed Care and Medicare. The presenter will discuss elements to address managed care plans that can be incorporated into your pre-admission screening process. You will learn how to develop a system for Case Management for SNF providers and explore common Managed Care billing challenges. Learn how to fight the good fight! Gain insight of where to verify reasons for payment denial, how to identify regulatory language to assist in disputing denials and how to fight claims through CMS.
Learning Objectives:
Recognize payment denials for unfounded CMS regulations.
Locate various SNF regulations governing reimbursement.
Implement best practices for addressing denied care including a robust medical review process.