Keys to effectively manage Medicare Advantage plans

Billing: One of the biggest challenges with MA plans is knowing how to bill. Some want you to bill episodically, and some want billing per visit. Another difference is the required turnaround time: Many MA plans allow only 120 days, compared to 365 days for Medicare. If you miss that shorter window, it can really affect your bottom line. To make sure you’re meeting requirements, it’s important to know the details of your contracts and talk with your provider reps.

Prior authorizations: MA plans generally require prior authorization, and that means more processes for you to manage. It’s vital to get timely authorizations. Some plans will not do retroactive authorizations which means if the request isn’t made on time, you may not get paid.

Eligibility: Multiple payors offer multiple plans and sometimes people don’t understand what they’re signing up for or have a clear understanding of their own coverage. Eligibility is important from an agency perspective because it could change at any time. In addition, patient churn in MA plans adds to the confusion, which makes consistently checking eligibility even more important.

Agencies should have a system to help check eligibility and should run it weekly to compare it against previous lists so changes will show up. If you don’t stay on top of it, you’ll need a new start of care date, and you’ll need authorizations for most of them. We recommend running eligibility weekly — but given the sheer volume of Medicare and MA patients, that can be a big task.

After running the report, make sure you take the time to review it. You should not assume Medicare is always the primary payor. Without reviewing, it might take six months before you realize Medicare shouldn’t have been billed and it should have been a private payor like Humana, for example. And after that much time has passed, you’re not going to get paid for the care and services you provided. Too often, agencies assume Medicare is primary because it’s easier to deal with, and they don’t check eligibility as often as needed.

Knowledge gap: Agencies deal with many different insurance payors, and each one has its own billing requirements — on top of the regular Medicare requirements. Keeping up with these different requirements can be overwhelming for anyone, especially alongside all the other responsibilities of their role.