Providers feel shut out from managed care

Friday, October 2, 2015

YARMOUTH, Maine – Record numbers of beneficiaries are enrolling in Medicare Advantage plans, but with many of those plans locking down their markets to a handful of providers, that doesn’t always translate to an increase in business for HME providers.

“We do very little with MA plans,” said Ron Evans, owner of Phoenix-based Valley Respiratory Services. “In Phoenix, 95% is wrapped up with two DME companies. They do capitated contracts and they tend to get redone every year without anyone ever being able to bid on them.”

In September, CMS announced that enrollment in MA plans is projected to increase to about 17.4 million enrollees—about 32% of the Medicare population. The agency said premiums will decrease by about $0.31 next year, from $32.91 on average in 2015 to $32.60 on average in 2016.

Provider Robin Powers would like to be able to get in-network with more plans in her region.

“The most common ones in our area—UnitedHealthcare and Humana—are closed networks,” said Powers, billing supervisor for Friendship Home Medical Equipment in Wise, Va. “We have tried numerous times to get in.”

Friendship Home Medical Equipment does some subcontracting for Apria Healthcare, which is a contract provider in the area but has no local offices, Powers said.

For those providers in-network with managed care plans, it’s not a bad gig. Regional player Advanced Home Care contracts with several plans, including UnitedHealthcare and Humana.

“For the most part, they follow Medicare guidelines and they are easy to work with,” said Laura Williard, senior director of regulatory affairs, compliance and contracting. “Sometimes our pain is more upfront, with prior authorizations.”

One way in which the plans, unfortunately, are following Medicare: They are starting to audit more, Williard said.

Medicare isn’t the only place where managed care is taking off.

Many state Medicaid programs are shifting their patients into managed care. Providers wonder if the recent collapse of Univita Health, which administered DME for the bulk of Florida’s managed care plans, will impact that trend.

“The Univita debacle has really opened some insurance company eyes,” said Williard. “I do still think we are going to have a small select group of providers. It’s more efficient and cost effective, and I don’t think that’s going to be outweighed by what happened with Univita.”