In this episode, we are joined by BESLER’s Olga Barone-Allan and Michelle Keller-Eiler for an in-depth look at Medicare Advantage updates in 2021 and changes related to Transfer DRG.
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Learn how to listen to The Hospital Finance Podcast® on your mobile device.Highlights of this episode include:
- Background on Medicare Advantage plans – how they operate and what’s new in 2021.
- How Medicare Advantage enrollment has increased and what enrollment trajectory numbers looks like.
- The impact of COVID-19 on Medicare Advantage.
- Tips for providers when addressing increased Medicare Advantage enrollees and expanded plan offerings.
- And more…
Mike Passanante: Hi, this is Mike Passanante and welcome back to the award-winning Hospital Finance Podcast®. Medicare Advantage continues to grow in every aspect: enrollment, available plans, and services offered. To explain how these plans are changing and the impact to providers, I’m joined by Olga Barone-Allan and Michelle Keller-Eiler of our Revenue Cycle Services team at BESLER. Olga and Michelle, welcome back to the show.
Olga Barone-Allan: Thank you, Mike, for inviting us.
Mike: So, Michelle, let me turn to you first. Most people in our audience will be familiar with Medicare Advantage plans, but could you give us a brief overview of what they are, how they operate, and what’s new in 2021?
Michelle Keller-Eiler: Hi, Mike. Sure. So Medicare Advantage plans, MA plans, Medicare Part D, Medicare HMO, we call them so many different names and we know they’re just a bundled plan offered by a private company which are approved by Medicare. These plans include all of the covered services that Medicare Part A and Part B would cover. And now many of the plans are even including Part D prescription coverage. Each year, the plans add more and more supplemental benefits. It keeps growing. And in 2021, with recent CMS rulings, the plans have expanded flexibility and the benefits that they can offer to some members. They don’t have to offer it to all members. The plans actually get to choose if it will be– if the services will be available to all members or if it would just be to a certain population with perhaps a certain medical condition. The expanded services are now including telehealth, which we know are super important, especially right now with COVID, transportation services, non-skilled home care services, safety equipment, such as bathroom equipment that may help some of our older population be more comfortable and safer at home. Home-based palliative care services, meals services, nicotine replacement. One cool program called the Silver Sneakers Program is an exercise program that a lot of plans are offering now. And then they’re also having prescription and preventative medicine plans, such as for patients with diabetes. The idea that they’re pushing is really to try and keep people healthier and keep people out of acute care settings, keep them home and healthy. Unfortunately, with that, the enrollees really have to pay attention to what their needs are and what the plans offer because there’s so many options out there that, to make an informed decision, it’s not actually all that easy because there’s so many different things available now. One key change in 2021 that is pretty exciting for Medicare Advantage is that end-stage renal disease patients are now able to choose a Medicare Advantage plan as part of the 21st-Century Cures Act these patients, which often have other medical conditions and they require extensive and expensive medical care throughout the year, are now able to choose an MA plan. Prior to this, the only plans available were very few C-SNP plans, which is one of the Medicare Advantage special needs plans for chronic conditions. And now in 2021, they are able to choose from many, many more of the Medicare Advantage plans.
Mike: Thanks, Michelle. Olga, Medicare Advantage plans have been increasing in popularity. What does the enrollment trajectory look like?
Olga: Yeah, it’s really interesting when you look at these numbers and when this all came out, Medicare Advantage, it was like everyone was so afraid to even embark on that, but based on the latest information from CMS for July 2019, there were nearly 22.4 million MA enrollees for HMO and PPO. In 2020, it grew over 24 million. And they’re projecting through 2021, there’s going to be over 26 million enrollees. The interesting factor as to why this is increasing exponentially is because the baby boomer generation is now reaching retirement and they’re used to a commercial employee sponsored HMO and PPO plan. So they’re staying with a similar plan. They’re already familiar with this. So they’re already in that comfort zone. The other factor is that it’s an all in one insurance. It has extended benefits and it has a low monthly premium, which helps obviously in this day and age. The fact that the enrollee does not need to worry about finding an additional Medigap or a secondary plan helps tremendously and makes it so much easier in processing and getting claims paid. Additionally, CMS is committed to making the selection process easier for their beneficiaries. So they come out with a Medicare plan finder and tool, which makes the selection process so much easier than it did in the past. And lastly, new companies are joining Medicare Advantage Arena, which has expanded offerings all over the country. United Health Care, Humana, Blue Cross continue to be the largest enrollment. The number of plans available overall has increased significantly over the past years with over thirty five hundred plans available in 2021, which is huge. This increase has been noted more in local PPOs rather than regional PPOs, which has remained constant. The availability also varies by the state and county with the greatest increase in plans available shown in Florida and California. And as Michelle indicated earlier, it has also increased in the special needs plans available for 2021. So all these factors have really helped enrollees to really shift from traditional Medicare into Medicare Advantage plans.
Mike: Michelle, what was the impact of COVID-19 on Medicare Advantage plans?
Michelle: So as we know, COVID-19 has had major impacts across all aspects of health care including the plans all health plans not just Medicare Advantage from decreased admissions to you not being able to have elective procedures done, patients fearing getting routine care. It’s a problem across the board. Due to COVID though, many of the MA plans have put programs into place to allow ease of care for their patients, ease of credentialing for providers, the allowance of non-hospital settings to be used for and billed at a different level of care. This is a program known as Hospitals Without Walls, which became very important when we had our hospital beds are full and we needed to have skilled care outside of that setting. And we needed to have a place for patients to receive the levels of care that they desperately needed. And there just weren’t any beds available in the regular hospital as we know it. So these pop up facilities became available for these patients. And my plans just went with it and allowed for this to be billed and the patients to receive the care that they need it. For most Medicare Advantage patients, there was no cost sharing for COVID-related testing, treatment, telehealth visits. However, with that said, the start and date of the free care was determined by the health plan. So it’s important to monitor what those dates were. Some started in March of 2020 and ended in March 2021, and others started in June of 2020. So it really varied by plan, although most of them did have that no cost sharing benefit. It just depends on when they started it and when they ended. The COVID vaccine is available at least here in New Jersey now to almost everyone. And that’s also going to be a covered benefit to most members. Some plans also waved non-COVID-related services just to encourage patients to continue with their routine healthcare so they didn’t land in a hospital for something that could have been managed in an outpatient setting. From a provider standpoint, there were some instances in which the plans offered accelerated credentialing process, and that was done to assist in fulfilling a need for providers for COVID care. There were waivers and additional allowances that were also put in place by some fans. Some of those waivers included waiving referrals for network care, utilization reviews, for COVID-related testing and treatments, pre-authorizations for emergent and urgent transfers to a skilled nursing facility. The purpose of that was to free up that space for more COVID positive inpatient cases. There was also some settings in which emergency services and transportation were flexible, and they weren’t required to be authorized. Sequestration adjustments were being withheld. There were an increase in COVID payments related to COVID DRGs and diagnosis code specific to COVID screening and treatment. However, I just want to make a note that with those specific diagnosis codes and DRG payments related to COVID , there are some specific requirements with testing requirements and using correct diagnosis and CPT codes for phase in order to get that additional payment. So just something to be mindful of is that these services were made available, but there are some requirements around them.
Mike: Olga, do you have any tips for providers, as many are likely to see increases in their Medicare population over time?
Olga: Absolutely. With the growing number of the MA enrollees and the expansion of the plan offerings, providers need to really review their contract language. In the past, it was pretty boilerplate templates for contracts. But now, especially with these Medicare Advantage, Michelle listed a handful of scenarios that need to be included. The contracts really need to evaluate as the Medicare plan follow the Medicare rules especially, but they have the ability also to control their payment methodology rules, which conflicts on the back end when you’re trying to process a reopening or appeal an account. The language such as Medicare methodology versus Medicare rates should be reviewed in a contract setting, timely filing periods, the extension of those periods of sequestration. And add-ons must be really, really closely reviewed and outlined in the contracts. Medicare Advantage plans seek to keep patients healthier, and this creates an opportunity to work with your contracted and make plans to create awareness and education through marketing of service and offerings. It is also important to verify that the coding of the claims falling under COVID-19 related services, following positive test requirements for additional DRG reimbursement and using the correct diagnosis codes for stayed visits, telehealth visits, testing and supplies, and making sure that these codes are not only in the contract, but they’re shared with the various departments such as HIM and Patient Financial Services. So, for example, contract language, one of the main examples that we see on our end is the Medicare role is often not included in the contracts in the reopening for good cause. Medicare allows you to reprocess these claims or reopen these claims under certain circumstances. However, many plans, even though they claim they follow Medicare rules, do not follow this. And they are very strict on timely filing within the timely filing limit without any extension if there is a good cost for reopening. This creates a lot of loss on the provider side. There are times that there is a tight time filing period of 90 days. So you can imagine how tough that is to process a claim and then try and reopen that claim within that timely filing period. When we review claims that fall under the post-acute care Transfer DRG rule to ensure hospitals are reimbursed correctly, we identify the underpayment due to the plan of care not being received as expected at the time of discharge. Additional payment is to the hospital. However, given the strict timeline in some contracts, it’s often difficult to assist the facilities to obtain that additional reimbursement that they deserve. Allowing time for a thorough review of the post-acute takes time in the cases where there’s 90 day time filing period, and that’s impossible to even extend to do those reviews. I would recommend that taking the Medicare regulations and then trying to mimic those regulations into your Medicare Advantage contracts is key to make sure that the reopening of claims under the good cause rule is included and expanding the timely filing period. 90 days, 180 days just doesn’t cut it. Expanding it to at least a year, if not more, would help get that additional reimbursement.
Mike: Michelle and Olga, great insights. And for anyone in our audience who would like to hear more about Medicare Advantage and its effect on Transfers and how that’s involved, Olga and Michelle have delivered a webinar on that topic. It gets into a lot more detail around this topic. Feel free to head up to besler.com. Go to our Insights page, click on Revenue Cycle, and you will see a recording of that webinar that you can watch. Michelle and Olga, thanks so much for coming back to the podcast today.
