Guide your MA & MCO
customers so you can be reimbursed properly
by Dan Fedor Monday, June 7, 2021
Home medical equipment
(HME) suppliers have always had challenges in getting paid accurately and in a
timely manner for the items and services they provide to their customers. This
is an assumed cost of doing business, and suppliers persist despite the obstacles
because of the rewarding nature of taking care of customers.
There doesn’t seem to be
a greater challenge to the supplier as when a customer has a Medicare Advantage
(MA) plan or is under a managed care organization (MCO), which is the
outsourcing of state Medicaid programs to private insurance companies. A common
theme here is that the two major government health care programs—Medicare and
Medicaid—that are supposed to safeguard health care for seniors, low-income
adults, children and people with disabilities are allowing private insurance
companies to administer health care for this demographic.
Misleading Ads
Seniors are being
bombarded with television commercials from these private insurance companies,
sometimes posing as Medicare and often using likable celebrities sell their
Medicare Advantage plans. When you read the fine print, it becomes clear that
these plans are not affiliated with any government program or agency.
Below is a screenshot of
one such commercial featuring Joe Namath; it’s difficult to read the fine
print. Does anyone think a senior can actually read this while Joe is speaking
and other text keeps changing? Seniors may believe they are calling a real
Medicare representative who has their best interest in mind. However, the representative’s
goal is to convince seniors to select their MA plan over original Medicare by
touting that they offer all the standard coverage of Medicare plus additional
benefits with a lower out-of-pocket cost.
This leads to many HME
providers discovering that they must fight for every claim—and that they face
agencies using delay tactics or denying claims. Many plans reimburse at
unsustainable rates when they do pay.
How to Combat These
Issues
First, if there is a
contract offered to be in-network for one of these agencies, review it
thoroughly and make sure the coverage criteria, rates and payment processing
are acceptable. Ask to see details of how the plan matches Medicare in writing.
If you do not have a contract and a customer comes to you for equipment, verify
these details before processing the claim. If you can’t accept what a payer
offers for reimbursement, don’t. At that point, try to negotiate a fair
contract. If the insurance company won’t accept it, inform the customer why you
can’t provide them with the items they need.
Second, tell your
customers (current and new) where they can obtain unbiased information on the
differences between original Medicare and their MA plan. Some MA plan customers
may be able to get a gym membership and eyeglasses, but they may not be able to
obtain the wheelchair, hospital bed or oxygen they need. Educate your customers
and let them know they can select a different Medicare plan (or switch back) if
they find that the MA plan they chose isn’t working.
Medicare-eligible seniors
can call (800) 633-4227 (that’s also 1-800-Medicare) to speak an actual
Medicare representative for accurate information about selecting the best plan
for them. There are also people who specialize in helping seniors navigate the
Medicare marketplace.
Helping Medicaid Patients
Medicaid patients who are
moved to an MCO are in a more difficult position because they were placed in
the program by the state. They don’t have the option to switch back to the
state’s Medicaid program since the state outsourced this function to the MCO.
What can you do when you want to help the patient, but the MCO is using
delaying tactics, inappropriately denying claims or paying at a rate that you
can’t accept?
Contact the MCO to
express your concerns and let them know you can’t continue servicing patients
on their plan if these issues are not corrected. If that doesn’t work, then
contact your state’s insurance commissioner, your state representatives and
your congressional representatives. Be prepared to share the details of how
their actions are negatively affecting your business and patient care. They
will ask for examples, so have them ready: how long claims are delayed,
incorrect denials and unacceptable payment rates.
If suppliers keep
accepting delays in payment, incorrect denials and unsustainable rates, the
Medicare Advantage plans and MCOs will continue taking advantage of suppliers.
It’s easier said than done, but suppliers must stand up to the bully to initiate
the changes needed to ensure fast and accurate reimbursement as well as
sustainable rates so they can continue taking care of their customers.
Dan Fedor is director of reimbursement for US
Rehab, a division of The VGM Group Inc. Fedor has been in the home medical
equipment industry for over 28 years. He joined VGM in 2014 and before that,
was the director of education and compliance for Pride Mobility
Products/Quantum Rehab for 13 years. Fedor has presented at numerous local and
national events regarding Medicare compliance and reimbursement including
Medtrade, the Heartland Conference, ISS, RESNA and multiple state association
meetings.
https://www.homecaremag.com/june-2021/medicare-advantage-guide-customers
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