Managed Care Contracts: Medicare and Medicaid Considerations for Providers Reimbursement and Delegation Challenges, Key Provisions and Anticipating Areas of Dispute Today’s faculty features: 1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific The audio portion of the conference may be accessed via the telephone or by using your computer's speakers. Please refer to the instructions emailed to registrants for additional information. If you have any questions, please contact Customer Service at 1-800-926-7926 ext. 1. WEDNESDAY, MARCH 20, 2019 Presenting a live 90-minute webinar with interactive Q&A Clifford E. Barnes, Member, Epstein Becker & Green, Washington, D.C. & New York Christian Puff, Attorney, Hall Render Killian Heath & Lyman, Dallas
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Managed Care Contracts: Medicare and
Medicaid Considerations for ProvidersReimbursement and Delegation Challenges, Key Provisions and Anticipating
1. Total Medicaid enrollment in any type of Managed Care represents an unduplicated count of beneficiaries enrolled in any Medicaid managed care program, including comprehensive MCO, limited benefit MCO and DCCMs.
Source: Henry J. Kaiser Family Foundation Total Medicaid Managed Care Enrollment.
▪ Medicaid Managed Care provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs) that accept a set per member per month capitation payment for these services.
▪ Each state is given flexibility to set its own eligibility requirements. Therefore each state evaluates its applicants independently from each other state. Any one desiring to transfer coverage from one state to another must re-apply for Medicaid in the new state.
▪ To support State efforts to advance delivery system reform and improve the quality of care
▪ To strengthen the beneficiary experience of care and key beneficiary protections
▪ To strengthen program integrity by improving accountability and transparency
▪ To align key Medicaid and CHIP managed care requirements with other health coverage programs
Source: Centers for Medicare & Medicaid Services, Medicaid and CHIP Managed Care Final Rule (CMS 2390-F) Strengthening States’ Delivery System Reform Efforts (Apr. 25, 2016)
▪ To support state and federal delivery system reforms, the final rule:
• Provides flexibility for states to have value-based purchasing models, delivery system reform initiatives, or provider reimbursement requirements in the managed care contract
• Strengthens existing quality improvement approaches with respect to managed care plans
▪ States have enhanced their ability to hold MCOs accountable for performance metrics through increasing emphasis in pay-for-performance (P4P) programs.
▪ State regulators are defining metrics that measure the quality, efficiency and value of health care provided to a population as incentives for care providers to optimally care for patients
▪ States utilize a range of ways to incentivize MCO performance. Some of the ways include upside incentives such as bonus payments to MCOs that achieve prescribed quality thresholds.
▪ Some of the ways include downside incentives such as withholds and penalties wherein portions of payment to the MCOs are withheld allowing MCOs to recover payment only upon achievement of quality thresholds
Upside Bonus payments States offer bonuses to MCOs achieving certain quality benchmarksBonuses typically range from 0% to 5% of revenue
Downside Withhold States withhold a portion of capitation payment on an annual or monthly basis and allow MCOs to recover payment only upon achievement of quality benchmarksStates typically withhold between 1% and 10% of capitation payment
Downside Penalties States charge fines or place sanctions on plans that fail to meet certain quality standards
Upside and downside Auto-assignment preference States preferentially place members who do not actively select a plan into plans with high quality scores
Shared incentive pools States withhold a portion of payment and pool the withheld funds from all MCOs to create an incentive pool MCOs can earn money from the incentivepool based on performanceStates typically withhold from 0% to 5% of revenue per plan
Differential reimbursement States increase or decrease capitation payments based on plan performance
Source: Toward the Stick (From the Carrot): The Evolution of Medicaid MCO Pay-for performance Programs. By Todd Clark, Joan Kim, Neil Menzies. L.E.K. Consulting’s Healthcare Service Practice
▪ Ohio Department of Medicaid began a P4P program beginning in 2012
▪ Ohio calculates and pays a bonus amount for each participating MCO based upon the percentile scores (relative to national benchmarks) across seven HEDIS measures including:
• Timeliness of prenatal care• Postpartum care• Controlling high blood pressure for patients with hypertension• Seven day follow-up after mental illness admission• Adolescent well-care visits• Appropriate treatment for children with upper respiratory
▪ Because payments are in part federal funds, applicability of federal laws including False Claims Act (31 U.S.C.§3729 et. seq) and Anti-kickback Statute (42 U.S.C.§1320a – 76b(b))
• Submission of false claims/statements
• Misrepresentation
▪ State Monitoring of MCO operations 42 C.F.R. 438.66
• State shall have procedure in effect for monitoring MCOoperations (typically in provider contract)
• Payment for Providers
▪ Provider agrees to timely access to care and member services
Medicare Managed Care Contracting –
Current Contracting Trends
Medicare Contracting Trends
• Value Based Contractingo Payors' goal: align incentives to reach the best
outcomes▪ Increased outcomes = lower cost over the long term
▪ Utilizing data to pinpoint where the issues are, what to
attack, and how to better integrate between providers
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Medicare Contracting Trends
• Value Based Contractingo Providers' take:
▪ The pace of this type of contracting is slowed by
provider's unwillingness to take on downside risk
▪ Payors' are reluctance to push provider systems into it
before they're ready, otherwise, it’s unlikely it will work▪ Provider Systems need an aligned group of participating
providers
▪ That starts with a strong definition of alignment, and buy
in from all of them
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Medicare Contracting Trends
• A Shift from IP to OP, Wearables and Telemedicine o Delivery of care is moving out of the acute care setting
and into the OP setting
o Allows patients to been seen in an appropriate level of
care setting, and is being driven by bundled payment
arrangements, which increase the utilization of
wearables (such as devices that alert treating providers
of issues when necessary), will further lower costs by
using telemedicine, rather than incurring more pricey
acute care face-to-face physician and facility costs
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Medicare Contracting Trends
• Consumer Driven Cost and Quality Transparencyo In the world of HDHPs, consumers are becoming more
price conscious than ever before
o According to a study conducted by HealthFirst
Financial, Millennials have said they are likely to more
likely to switch providers if offered more favorable
financing options
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Medicare Contracting Trends
• Payor/Provider Partnershipso Healthcare has turned into a hybrid world
• Provide Quality Data (figuratively and literally) showing
significant delivery system reforms and reduced cost through:
o Care Coordination – improve care coordination, which
should ultimately reduce both the acute and post-acute care
costs
o Holistic Treatment – remove silos to the extent possible,
focusing on the whole person, including behavioral health
and community needs
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Practical Tips for Providers in Negotiating
Medicare Agreements
• Become and/or show the payor that you can become part
of a Community Based Network ("CBO") which
combines access to the right level of care at the right time
and place with social services support, as well as
enhancing care management and utilization review
capabilities while leveraging evidence-based clinical
practices and strong data analytics
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Practical Tips for Providers in Negotiating
Medicare Agreements
• Be Preparedo Without sufficient data, it is nearly impossible to know
when it's time to move from FFS into a risk and/or
value based arrangement
o If the healthcare system is already participating in
MSSPs, ACOs and/or BCPIs or BCPI Advanced, the
system can utilize that as a segue into more up and
downside risk arrangements
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Practical Tips for Providers in Negotiating
Medicare Agreements
• Compensationo Percentage of Medicare
o Provider Type Matters
• So How Can we Get Paid More Money?o Give them what they want
o Prove You're Worth It Through Strong:▪ FDR and Delegated Oversight
▪ FWA Understanding and Training
▪ Care-Coordination Starting With PARE Providers
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Practical Tips for Providers in Negotiating
Medicare Agreements
• FDRs and Delegation Oversighto Know who your FDRs are and train them
o Make sure they are meeting goals and complying with the
rules:o Delegated Oversight Committee
o Hold the regularly
o Capture data for each
o Create Corrective Action Plans (“CAP”s)
o Include Quality Metrics
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Practical Tips for Providers in Negotiating
Medicare Agreements
• Fraud Waste and Abuse (“FWA”)o Ensure you are steering clear of FWA issues by having a
strong Compliance Program that aligns with the Payors’
o Utilize CMS website to build a program with the 7
Elements of compliance▪ Written Policies, Procedures and Standards of Conduct
▪ Compliance Officer, Committee and Oversight
▪ Effective Training and Education
▪ Effective Lines of Communication
▪ Well-Publicized Disciplinary Standards
▪ Effective Systems for Routine Monitoring and Auditing
▪ Procedures for Prompt Response to Compliance Issues
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Practical Tips for Providers in Negotiating
Medicare Agreements
• PARE Providerso Pathologists, Anesthesiologists, Radiologists,
Emergency Department (“PARE” Providers)
o Encourage and/or insist via an RFP that these
providers are participating in your contracted Medicare
Advantage Plans▪ Be careful though…this is not always popular and
requires significant provider buy-in
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This presentation is solely for educational purposes and the matters presented herein do not constitute legal advice with respect to your particular situation.
Christian K. PuffHall Render Killian Heath & [email protected] @cpuffattorney
Please visit the Hall Render Blog at http://blogs.hallrender.com for more information on topics related to health care law.