Understanding medicaid managed long term care contracting september 11 2013
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Understanding Medicaid Managed Long Term Care Contracting September 11, 2013. LeadingAge New York Financial Managers Annual Conference. Michael H. Lewensohn Manager Health Care Medical Reimbursement Services [email protected] Discussion Topics. Definitions Contract assessment

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Understanding Medicaid Managed Long Term Care Contracting September 11, 2013

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Understanding Medicaid Managed Long Term Care ContractingSeptember 11, 2013

LeadingAge New York

Financial Managers Annual Conference

Michael H. Lewensohn

Manager

Health Care Medical Reimbursement Services

[email protected]


Discussion Topics

  • Definitions

  • Contract assessment

  • Facility specific costs and potential data resources

  • Communication

  • Other Issues


Definitions

  • Managed Care

  • MLTC (Managed Long Term Care)

  • MCO (Managed Care Organization)

  • Capitation

  • Coordination of Care

  • FIDA (Fully Integrated Duals Advantage)

  • SNP (Special Needs Plan)


Definitions(continued)

  • PACE (Program of All-Inclusive Care for the Elderly)

  • Evergreen Agreement

  • Dual Eligible

  • Formulary

  • Included Services

  • Excluded Services

  • Capitation / Fee-For-Service


Contract Assessment

  • Rates

    • Multiple levels of care, based on patient needs and assessment

      • Identify documentation requirements by level of care

  • Included and Excluded Services

    • Pharmacy formulary

    • Rehabilitation

    • Medical services

    • Medical Diagnostic Testing (Labs, X-Ray, Supplies)


Contract Assessment (continued)

  • Billing Protocols

    • Identify billing submission period

    • Identify the billing appeals process

  • Care Requirements

    • Delivery of care and documentation requirements

    • Patient assessments to support level of care/payment

  • Credentialing of Facility Professionals

    • Medical staff, Rehabilitation, Testing & Supplies


Contract Assessment (continued)


Contract Assessment (continued)


Identifying Facility Specific Costs: Potential Data Resources

  • Medicare and Medicaid cost reports

  • Internal facility reports

  • Vendor historical data

  • Available “public information” about neighboring providers

  • Information available through trade organizations


Communicating MLTC Issues

  • Staff training and ongoing communication of contractual changes

  • Vendors

    • Apprise vendors of when bills should be sent to the Facility versus other 3rd party payers

  • Patients and Families

    • Apprise patients and or families of costs which they may be responsible to pay


Other Issues

  • Facility Admission Agreement: the Facility’s contract with patients

    • The MLTC agreement versus the Facility Admission Agreement

  • Avoid Evergreen Contracts

    • Request specific start and end dates of agreements

    • Identify when re-negotiation period begins

  • Consult legal counsel


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