Lesser of two evils

Medicare Advantage: Positives outweigh negatives
Friday, May 17, 2013

YARMOUTH, Maine – Some Medicare Advantage (MA) plans are starting to look more and more like traditional Medicare, industry sources say.

In the wake of CMS’s announcement of the Round 2 payment amounts, a Blue Cross Blue Shield MA plan in one state, for example, has shaved 10% off its reimbursement for HME. Another plan going in that direction: Windsor, says Tyler Poole.

“We anticipated this,” said Poole, vice president of operations for Benefits365, a company that helps providers shift beneficiaries from traditional Medicare to MA plans. “We thought they would make a move—we hoped they wouldn’t, but we thought they probably would—but we don’t think there’s any chance they’ll make a 45% cut.”

As part of Round 2, that’s the cut that will be in place for providers serving traditional Medicare beneficiaries in 91 cities starting July 1.

There are also reports of increased audit activity for providers that service MA plans. Peggy Walker has received five of these audits from providers in recent weeks.

“It’s just a few, but providers need to know these audits are coming and they need to be prepared,” said Walker, a billing and reimbursement advisor for U.S. Rehab, a division of The VGM Group.

Because MA plans follow the guidelines for traditional Medicare, the audits should be mostly familiar territory. Where some providers are getting tied up: Their contract says one thing, and they’re being told another thing.

“Just because you call and speak with a representative and you hear what you want to hear, it doesn’t necessarily equate to a commitment from a policy perspective,” said Andrea Stark, a reimbursement consultant with MiraVista. “Everything has to be in writing or from an official directive.”

Even though MA plans aren’t totally free from reimbursement cuts and audits, for providers like Banner Home Care, which is not a contract supplier under competitive bidding, this business has become a priority.

“It’s at least 50% of our business and growing,” said Susan Kirchhof, director of HME for the Gilbert, Ariz.-based provider, which is an affiliate of Banner Health. “We’re going after as many contracts as we can.”

And there may be more of them to get. In its annual review of the federal budget in May, the Congressional Budget Office stated it believes MA plans will swell to 21 million participants by fiscal year 2023, from 14 million this year.