Maintaining a place in a Medicare Advantage payer’s network requires far more than signing an agreement.
Providers need to demonstrate reliable access, quality outcomes and a willingness to work with plans on an ongoing basis — increasingly through timely performance data and regular communication, industry experts said during PAYER Summit in June.
“I often see providers, they get that contract, and then there’s no communication back and forth between the two sides,” said Chris Cycak-Dyos, director of strategic network operations at Helion. “I think that’s where providers often fail.”
Pittsburgh-based Helion is a healthcare technology and services provider augmenting home- and community-based care through technology solutions, data and reporting and subject matter expert consulting.
To strengthen their position within payer networks, providers should shift from managing care on a visit-by-visit basis to managing the full episode of care to strengthen their position within payer networks, Cycak-Dyos said. The approach can benefit both providers and patients or health plan members by centering care management on the broader course of treatment rather than individual visits.
Providers also need to bring their own performance data to payer conversations, Cycak-Dyos said. Providers and payers both struggle with obtaining timely, high-quality data, noting that claims data can be six months behind. Still, providers should establish their baseline performance and understand both operational measures and patient outcomes, then bring their data to payer conversations.
“Showing that you have an understanding of your own data just really sets you apart from others,” Cycak-Dyos said.
Matt Lippitt, vice president and division director of Bayada Home Health Care, said that data creation, collection and analysis are crucial in the home-based care industry.
“The beginning of a payer relationship is really the data sharing…and understanding what the expectations of the relationship,” Lippitt said.
Founded in 1975, Pennsauken Township, New Jersey-based Bayada Home Health Care provides adult and pediatric home health, personal care, hospice, private duty nursing, companion care and other services across 20 states.
Payers are looking for providers that can demonstrate quality improvement, dependable access and reliability, Lippitt said. Data helps Bayada show payers how it is performing against those measures and whether it is on track to meet shared goals.
Bringing in clinicians and teams
Provider organizations can also benefit from bringing clinical teams into contract discussions, Cycak-Dyos said. This practice helps leadership understand what the contract requires and address potential issues ahead of time.
“Having their clinical teams and their resident teams in the same room discussing contract clauses, rather than learning that through denials, is such an important proactive step,” Cycak-Dyos said.
Justin Meara, senior vice president of managed care at Ignite Medical Resorts, similarly emphasized the importance of maintaining regular communication with MA plans after signing a contract.
Park Ridge, Illinois-based Ignite Medical Resorts provides skilled nursing services, orthopedic rehabilitation, palliative care and other services across seven states.
When one of Ignite’s facilities in Texas faced friction with a payer, Ignite set up weekly meetings with a group of senior leaders to listen to the payer’s concerns, Meara said. The approach demonstrated Ignite’s commitment to quickly addressing issues, he said
“You just need to show that senior leadership wants to be involved, to communicate and to make sure that we have a great partnership, as we’re both working towards the same goals,” Meara said.