GAINING CLARITY: Effective case management can help you maximize reimbursement and ensure compliance with the unique rules from each managed care payer. In this Clarity Guide, we detail Medicare Advantage case management strategies for post acute providers to improve their work with managed care payers.
Skilled nursing homes and home health agencies can improve how they work with Medicare Advantage payers to ease daily case management workloads, increase pre-authorization success, win appeals and ensure timely reimbursement for the care provided. Apply these best practices to ensure secure fair managed care reimbursement from your payer partners.
Best Practices for Medicare Advantage Case Management
Always Be Prepared
Conduct a detailed assessment of the patient’s healthcare and social needs. Create a personalized care plan that sets treatment goals, outlines necessary services, and navigates potential barriers. Establish and train your internal team to be ready for the nuances of each payer.
- Know the Requirements: Get familiar with the specific pre-authorization and clinical documentation requirements of every Medicare Advantage (MA) plan you work with.
- Plan the Journey: Use detailed checklists to ensure all beneficial documentation and information are gathered before submitting pre-authorization requests
- Stay Ahead of Changes: Regularly review and get updates about any policy or process changes and adjust your internal tools accordingly
- Cross-Training: Ensure multiple staff members are proficient in pre-authorization and appeals processes to handle urgent needs.
- Secure Physician Collaboration: Foster strong relationships with physicians to ensure timely completion of required documentation and support for continued stay requests.
Maintain Complete & Accurate Documentation
Maintaining and sharing with payers your thorough, real-time documentation of all care provided and patient progress is key to effective case management.
- Clinical Justification: Ensure your documentation clearly supports the medical necessity of provided services, which is crucial for pre-authorization and appeals.
- Regular Case Reviews: Conduct interdisciplinary team meetings to review patient progress and adjust care plans as needed.
- Develop Winning Templates: Use standardized templates for common appeal types, including all necessary documentation and evidence-based guidelines
Manage the Deadlines
Timing is everything, and providers have to stay vigilant to avoid missing critical deadlines and negatively affecting patient care and length of stay.
- Deadline Tracking System: Implement a system to monitor appeal statuses, ensuring timely follow-up and resolution
- Payer Communications: Establish strong relationships with payer representatives and maintain clear, open communication channels.
- Regular Meetings: Hold regular interdisciplinary team (IDT) meetings to review ongoing cases, anticipate changes in patient care needs, and adjust care plans accordingly
Win your Medicare Advantage Appeals
Even the best Medicare Advantage case management will not eliminate the need for appeals. Plan for and regularly appeal denials from managed care payers. Here are keys to understanding the appeals process:
- Understanding Member Rights: Ensure members are fully informed of their appeal rights and the process for filing an appeal.
- Thorough Documentation: Maintain meticulous records of all interactions, care plans, and communications with members. This documentation is crucial during the appeals process.
- Timely Filing: Adhere to payer’s strict deadlines for filing appeals. Delays can negatively impact member outcomes.
- Clear and Concise Appeal Letters: Craft appeal letters that clearly articulate the reason for the appeal and provide supporting evidence.
- Collaboration with Providers: Work closely with other providers to gather the necessary documentation that supports your appeal.
- Internal Review Processes: Establish internal review processes to identify and address potential issues before they escalate to formal appeals.
Learn More About Managed Care Contracting
Check out these additional Clarity Guides or evaluate your Medicare Advantage contracts with Payer Truth software.
Stay current with CMS rules and regulations that apply to Medicare Advantage payers and read about the latest news to see what’s coming for managed care in post acute.
