CMS let the cat out of the bag, but it surely’s managed care that’s able to pounce – Every day Editors’ Notes

Kimberly Marselas

You’ve probably heard by now that your organization should be prepared for the impact of an adjustment that brings the patient-driven payment model back to budget-neutral status.

Well, it might be time to buckle up.

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The government said last month that the move to the new payments system in October 2019 accidentally sparked spending 5% or $ 1.7 billion more than intended and that the Medicare and Medicaid services centers did so in one way or another Way would have to call back.

So, dear provider, keep treating all of these COVID-19 patients, paying millions more than usual to meet wages and PPE, and by all means, open the doors to clinically complex Medicare patients who could help the Medicaid of your state to offset underpayments. Keep in mind that in the near future when you submit this invoice, CMS is going to shave itself a little fast.

And lest you believe that it can be a long time before you feel the pain, think again.

If you are using managed care (and who no longer), chances are good you are already on a collision course that has been set in motion by the federal government and is radiating future cuts.

“CMS didn’t keep it quiet, guess who else heard this information? That would be any managed care organization, “warned Susie Mix, CEO and President of Mix Solutions Inc., last week. “Just when we thought managed care was giving us some kind of break for a brief second, they always seem to add some kind of insult to the injury.”

In this case, they are already turning away from contracts they entered into at the start of PDPM when they largely agreed to pay qualified care providers that are comparable to those of the new model. Now the health plans are picking up on the CMS “overpayment” indictment and causing providers to enter into level-based contracts that reduce reimbursement to 90% of PDPM rates – at best.

During a webinar organized by PrimeCareTech on April 27th, 42% of the participants stated that they already had to convert some contracts from PDPM to Level. Mix said many more vendors will face this type of pressure over the next six months. She urged providers to make plans, understand the details of their contracts, and figure out how to maximize them before admitting patients whose coverage could be time-consuming in unprepared facilities.

“Please don’t start in three months,” she urged. “This is something you have to do now. … They (the plans) are very aggressive about not only cutting our interest rates by 30% to 40%, but they are also very aggressive about getting started now. “

Mix, who has been negotiating nursing home contracts with insurers for nearly two decades, said she had never “seen so many health insurers on the same page at the same time with one move”.

Even if CMS keeps its word and takes into account the contributions of the providers – resetting PDPM reimbursement rates over several years or capping the overall cut with further consideration of the effects of COVID-19 – you can’t expect Managed Care to take this into account in sweet time.

Otherwise, Mix warned, you might be taking more of the bill than CMS can imagine.

Kimberly Marselas is Senior Editor of McKnight’s Long-Term Care News.