FEATURED ‘Elephant in the Room’: Medicare Advantage a Huge Factor in CCRC Decision Making Around Nursing Home Services

[Northeast Agent]

‘Elephant in the Room’: Medicare Advantage a Huge Factor in CCRC Decision Making Around Nursing Home Services

Soaring costs associated with skilled nursing – and problematic payer sources – are making it harder for continuing care retirement communities (CCRCs) to

skillednursingnews.com

Moreover, with the growth of Medicare Advantage plans, which are linked to a higher rate of denial of skilled nursing services and delays in payment, CCRCs providing skilled nursing services may be forced to pare these down or cut them out completely, said Phil Chuang, senior vice president of healthcare services at HumanGood. Medicare Advantage is the “elephant in the room,” Chuang said, when it came to decision making around scaling back skilled nursing services from the CCRC.

MA plans currently reimburse 60% to 80% of what Medicare Fee-for-Service reimburses.

 

[somarco]

MA plans currently reimburse 60% to 80% of what Medicare Fee-for-Service reimburses

That could make it more difficult for seniors with MA plans to gain admission to the SNF.

 

[StephanieCJ]

If the SNFs would work together, they could negotiate higher rates. They aren't forced to take the contracts at a lower rate, they choose to. The flip side of this is, there are a plethora of SNFs who will keep someone for 100 days who does not technically qualify for their care, simply because the patient has OM and there is no accountability. They have abused the system for so long and now it's coming back to bite them.

 

[somarco]

plethora of SNFs who will keep someone for 100 days who does not technically qualify for their care,

Where does this rumor come from?

The attending has to attest that the patient needs care in an SNF before they can be admitted. Once admitted, the first Medicare recertification cannot occur later than 14 days following admission. Thereafter, the time frame for recertification cannot exceed 30 days.

 

[somarco]

If the SNFs would work together, they could negotiate higher rates. They aren't forced to take the contracts at a lower rate,

Providers sign contracts with MCO's, Medicare and other third party payers. Part of the contract states that they agree to accept the fee schedule in the contract as "paid in full".

The only negotiation is, take it or leave it.

 

[rmhaire]

The flip side of this is, there are a plethora of SNFs who will keep someone for 100 days who does not technically qualify for their care, simply because the patient has OM and there is no accountability.

Actually the exact opposite of this is true.

SNFs, HHCs, Nursing Homes and Hospice Providers are strictly regulated by Medicare. Has nothing to do with OM or MA.

There will always a few providers that try to play the system. Just as there will always agents that are just short of being outright crooks.

Maybe you younger agents should actually visit a nursing home or hospice provider. You'd be surprised what you might find.

You'll only get so much from a website or an article. But experience ain't one of them.

 

[Midlevel]

Actually the exact opposite of this is true.

SNFs, HHCs, Nursing Homes and Hospice Providers are strictly regulated by Medicare. Has nothing to do with OM or MA.

There will always a few providers that try to play the system. Just as there will always agents that are just short of being outright crooks.

Maybe you younger agents should actually visit a nursing home or hospice provider. You'd be surprised what you might find.

You'll only get so much from a website or an article. But experience ain't one of them.

Strictly regulated by OM. What a joke. I’ve personally seen Alzheimer’s patients ran through rehab like cattle in these facilities because they know that no one is looking at the claims. There is a reason why all these facilities want everyone on OM and a Med Sup, bc it’s a free for all. Only thing OM is more strict on is having to be in the Hospital before a stay where MA does not require it. A lot of those people under observation wish they had been on an MA plan.

 

[rmhaire]

Strictly regulated by OM. What a joke. I’ve personally seen Alzheimer’s patients ran through rehab like cattle in these facilities because they know that no one is looking at the claims.

This is not the first time you've used this reference. Was he or she a family member? Most Alzheimer patients don't do rehab. My wife had Alzheimers. On hospice for a little over eleven years. So yeah, I kinda know what I'm talking about.

There is a reason why all these facilities want everyone on OM and a Med Sup, bc it’s a free for all.

It's not a free for all. Just fewer hoops to jump through to get paid.

Only thing OM is more strict on is having to be in the Hospital before a stay where MA does not require it.

Actually they do. MA plans are required to cover everything OM covers. Don't know if you're getting this from a brochure or a carrier website but Medicare doesn't say that.

A lot of those people under observation wish they had been on an MA plan.

In general MA plans do not cover Under Observation either so there would be no advantage to being on an advantage plan versus OM.

And for the record, I've seen both OM and MA plans pay Under Observation claims. Has to do with the UO rule changes back in 2004.

 

[somarco]

3 day refresher course . . . from the source!

https://www.cms.gov/files/document/skilled-nursing-facility-3-day-rule-billing.pdf

To help SNFs decide about Medicare-eligible inpatient claims billing and payment, hospitals should give SNFs and patients (or their representatives), including Medicare Advantage (MA) Plan enrollees,
accurate inpatient hospital stay information. This information alone doesn’t ensure MA Plan coverage.

 

[Midlevel]

This is not the first time you've used this reference. Was he or she a family member? Most Alzheimer patients don't do rehab. My wife had Alzheimers. On hospice for a little over eleven years. So yeah, I kinda know what I'm talking about.


It's not a free for all. Just fewer hoops to jump through to get paid.


Actually they do. MA plans are required to cover everything OM covers. Don't know if you're getting this from a brochure or a carrier website but Medicare doesn't say that.


In general MA plans do not cover Under Observation either so there would be no advantage to being on an advantage plan versus OM.

And for the record, I've seen both OM and MA plans pay Under Observation claims. Has to do with the UO rule changes back in 2004.

So I'm wrong that they do not have to be in the Hospital for 3 nights before an MA plan will pay? MA observation copay is the same as a night in the hospital with the plans I use. Difference is with MA they could still get skilled nursing paid if they weren't actually admitted.


Yes, it was a family member and 14 other alzheimer's residents that got ran through daily until I put a stop to it. Sorry you had to go through that with your wife, it is a terrible disease. These patients weren't on hospice yet so guess that's why they thought they could do it.