A SNF Operating Model for Managed Care Success

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A SNF Operating Model for Managed Care Success

• April 23, 2009
• Dava Ashley, VP Operations West Covenant Care
• Jerri Ollett, MPA HealthCare Strategies

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Managed Care Success

• First-get a contract
• Prepare for utilization
• Clinical preparation
• Billing
• Controlling expenses
• Proactive operations
• Market for increased volume

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Contract Terms

• RUGs
• Percentage of RUGs
• Levels
• All inclusive rate
• Bed reservation
• Volume based rates
• Capitated

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Contract Terms

• RUGs or a percent of RUGs
• Assure that the payor can process the claims
• Monitor payments
• Assure for updated schedules
• Requires facility to do MDS

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Contract Terms

• Levels
• Most popular
• Assure that case management terms are part of the
  language
• Up to _____ minutes of therapy
• Up to _____ days per week
• High cost services addressed in every level

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Contract Terms

• Exclusions need to be managed
• May require the use of their network
• Invoices may need to be attached
• High cost pharmacy
• Unique DME
• TPN, compounding and lipids
• Wound care and supplies

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Contract Terms

• All Inclusive- Case rates or Per diem
• Gaining popularity
• Easy to process claims
• Case Management a necessity
• Contracts with vendors VERY helpful
• All order changes go through CM
• Good working relationships with doctors that
  follow to address expensive orders

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Contract Terms

• Bed Reservation Agreement
• Helpful when census is low
• Cements working relationships with acutes as well
  as managed care
• Admission / discharge process even more important
• Possibility of dumping
• Strategy for log jams

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Contract Terms

• Volume based rates
• Assure that there really is the volume to push
  into the higher rates
• Prepare for increased number of admissions and
  shorter LOS

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Contract Terms

• Capitated
• Not seen very much anymore
• Risky for SNF provider
• Must have exceptional Case Management
• Must have the physical capacity to handle the
  volume
• Working agreements for overflow

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Contract Success

• Consider a case manager
• Physician coverage
• Know the contracts
• Managed Care Triple Check with Contract Manual
  for reference

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Contract Success

• Central storage of the contract
• Contract Summary shared with all facilities
• ED, Clinical and Rehab
• Put the signature page under lock and key

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Contract Success

• The 5 Ws
• Who is the plan
• Who is the payor
• Where are the claims sent
• Who authorizes care
• Which contract is being used

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Prepare Your Organization for Managed Care

• Clinical Systems
• Billing Systems
• Expense Control Systems

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Clinical Systems

• Review Admission Process
• Admissions 24/7 REALLY
• Evaluate all shifts especially pm/nights for
  admission process
• Assessment Systems MDS 5 day, 14 day? Know
  how you are being paid
• LOS will be impacted

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Clinical Systems

• Case Management differs by building
• Must designate a point of contact for MCO
• Evaluate communication system, documentation
  system for Case Manager
• Discharge Planning must determine before day 1
• Train Nurses to understand different patient
  population

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Billing Systems

• Know your contracts payment terms,
• What is a clean bill as defined by MCO
• Evaluate communication system between your
  business office managers and case managers or
  directors of Nursing
• Understand exclusions and how to bill
• Understand therapy terms in the contract

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Billing Systems

• Prepare for an increased aging
• Most contracts are 60 day term even though the
  contract states otherwise
• Evaluate the admission process
• Validate and verify health plan within 24 hours,
  optimal prior to admission
• Who will do this? Business Office, Admissions?

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Expense Systems

• Know your contracts
• Work with vendors, lab, xray, pharmacy
• Expect increase in utilization
• Prepare a system to monitor by payor
• Do a cost analysis by patient by payor to
  understand your margins
• Look at books of business
• Think volume...not one patient

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Expense Systems

• Pharmacy Utilization Management
• Review admission process
• Look at high drugs get exclusions
• Watch PRN medications
• LOS is low, evaluate supply sent, i.e. 14 day
  versus 31 day
• Evaluate a system for credits

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Marketing

• Determine the number of senior covered lives by
  payor source
• Senior lives equal 500 to 750 SNF days per 1000
  covered lives per year
• Commercial lives equal 10 SNF days per 1000
  covered lives per year

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Marketing

• How do you get more business from an MCO
• Educate hospitals and discharge planners about
  your contracts
• Ask the MCO about areas of need
• Understand what doctors have these patients

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Marketing

• Share your success with hospitals
• Understand the goal of the MCO which is reduced
  LOS
• Speak in their language, LOS, return to hospital,
  emergency room visits
• Understand how the MCOs work
• Assure that you have physician coverage for each
  contract

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Be Proactive

• Working with an MCO is a change
• Velocity is great
• Patients are educated consumers
• They selected this as a benefit
• Prepare your facility

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How do you prepare your facility to be proactive

• Educate staff about customer service
• This is a paradigm shift
• Population will be more demanding
• Cater to the patient and their families
• Staff wont have as much time to really get to
  know the patients

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How do you prepare your facility?

• Dedicate a unit
• Establish a culture of discharge planning
• Dedicate staff for the rehab unit train
• Staff to consider- unit manager, MDS coordinator,
  discharge planner,
• Activity program will be different
• Dining select menu

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How do you prepare your facility?

• Therapy education
• Difference between benefit programs, i.e.
  Medicare, Managed CAre, Private Insurance
• Train on the contracts
• Increase communication
• Team approach

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MCOs Expectations

• LOS
• One chance to make a good impression
• One knowledgeable and reachable contact
• They do not want to hear complaints
• When a problem occurs, call immediately
• Focused on the medical reason of admission not
  the entire list of medical issues

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MCO Expectations

• Looking for results
• Clear concise communication
• Discharge planning early in stay
• Satisfaction surveys good
• No bounce backs to acutes

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A Compelling Story

• From disaster to success
• Largest MCO in the area
• RUGs contract in place
• Empty beds in the facility
• Burned relationship
• Facility regrouped
• Trail admission--error and fixed
• 2 years later, largest payor for that building

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Future for Managed Care

• Medicare Advantage is cost effective to the
  senior
• Allows the government to project and control
  their cost
• The senior experiences little difference between
  Medicare and Managed Care

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Conclusion

• Managed Care is quickly coming across the U.S.
• You can be successful with some dilligent
  preparation of your organization

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Questions and Answers

• Thank you very much
• Dava Ashley 949-349-1200
• dashley_at_covenantcare.com
• Jerri Ollett 707-769-7481
• ollettrj_at_aol.com