Medicare Contracting Simplified: Your Comprehensive FAQ Resource

Navigating the process of contracting with insurance companies for Medicare reimbursement can be complex. That's why SimiTree experts Rob Simione, CPA, Principal, SVP Consulting, and Jonathan Dickinson, Senior Manager, Financial Consulting, hosted a webinar about winning in the Medicare Advantage market. Attendees asked excellent questions, and we’ve summarized our experts’ answers in this quick FAQ guide. Whether you're seeking contracts, negotiating terms, or understanding fee schedules, this article will help you gain clarity and navigate the contracting process more effectively.

Q: What suggestions do you have to obtain contracts? 

A: To obtain contracts with insurance companies, contact the regional representation of the desired insurance company and go through the credentialing process. This involves submitting the necessary paperwork and meeting the insurance company's requirements.

Q: How do we sign the contract? Contract best practices?

A: The administrator or owner of your organization should sign the agreement. Before signing, it is recommended to have the contract reviewed by legal professionals to ensure it aligns with your organization's interests. Aim for two-year contracts whenever possible for stability and navigate away from any "evergreen" or "no end date" contracts. 

Evergreen contracts are contracts that automatically renew unless one party gives notice of termination. This can be a problem if you are not happy with the terms of the contract or if the vendor's prices or services change. "No end date" contracts are even worse, as they can effectively bind you to the contract indefinitely.

By avoiding these types of contracts, you can give yourself more flexibility and control over your organization's future.

Q: What is the fee schedule?

A: The fee schedule refers to the reimbursement you receive for the services provided. It can follow the Patient-Driven Groupings Model (PDGM) guidelines or use a per-visit rate based on the discipline. Understanding your cost per visit is crucial in determining an appropriate fee schedule. Some refer to the fee schedule as the "Contracted Rate."

Q: What do you recommend doing when negotiations have started but the insurance representative is not responding (e.g., UHC)?

A: If negotiations are underway, but the insurance representative is unresponsive, continue reaching out to other sources at UHC. Set up a call or meeting to gather the necessary information for credentialing and submit it promptly. If possible, explore contacts in other agencies for potential assistance in reaching the payor representative.

Q: What key elements should we drive home in a Letter of Interest when reaching out to Medicare Advantage plans for contracting?

A: When approaching Medicare Advantage plans for contracting, emphasize the following key elements in your Letter of Interest:

  • Value and Depth of Services: Highlight the range and quality of services your organization provides, demonstrating the ability to meet the needs of Medicare Advantage beneficiaries effectively.
  • Volume and Size: Showcase your organization's capacity to handle variations in patient volume, demonstrating the ability to serve your population.
  • Quality Measures (tie to HEDIS measures): Emphasize your commitment to quality care and alignment with Healthcare Effectiveness Data and Information Set (HEDIS) measures. Highlight any quality improvement initiatives or achievements that set your organization apart.

Q: Do we need to submit pre-claim reviews to Medicare?

A: Pre-claim reviews are required only in certain states and do not apply to Medicare Advantage plans. Submit pre-claim reviews to Medicare only if they are mandatory in your specific state.

Q: Do you need to be CMS certified/accredited to work with Medicare Advantage plans?

A: Yes, Medicare certification is necessary to provide skilled services in the home for Medicare Advantage plans. This certification ensures that you meet the required standards and criteria to deliver care to beneficiaries under the Medicare Advantage program.

Q: Are there ranges of per-visit rates by payors?

A: Per-visit rates can vary among payors. It is recommended to determine your cost per visit by discipline and establish a range based on your desired margins.

While some Medicare Advantage contracts may allow for ranges, specifying a single rate per discipline is generally considered best practice. If ranges do exist, ensure visit types and codes are clearly identified in the contract to avoid any confusion.

Obtaining contracts with insurance companies for Medicare reimbursement requires navigating various steps, from initial contact to negotiation and agreement.

By following the suggestions provided and understanding key aspects such as fee schedules and certification requirements, you can improve your chances of successful Medicare contracting.

Remember to seek professional advice and stay proactive in your communication with insurance representatives to ensure a smooth contracting process. Learn more about How to Win in the Medicare Advantage Market in the webinar.

Talk to an expert today

We hope this FAQ was informative and helpful on your journey to secure Medicare reimbursement. If you have any questions or need assistance with the contracting process, our experts are here to help.

At SimiTree, we understand the need for a team that recognizes opportunities for growth, and development but also has the flexibility to fill gaps in areas with difficult processes and systems. SimiTree’s consulting experts can do just that. Our consultants specialize in home health, behavioral health, or hospice organizations of any size, with any budget. Learn how our experts can help your organization meet its growth or operational goals today!

What are you waiting for? To learn more about our services, fill out the contact form below or give us a call today at 1.800.949.0388.

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