Understanding contract exclusions and building staff expertise in managed care are emerging as critical competencies for facilities seeking to protect revenue and patient care. These developments collectively signal that MA plans are tightening utilization controls.
Successfully Navigating the Pain Points of Medicare Advantage at Nursing Homes
The growing prevalence of Medicare Advantage (MA) plans in many skilled nursing markets has been a source of mounting challenges for operators, many of whom are wondering whether they can keep up with the change. Yet a few strategies can go a long way to make the transition work, experts said. They cite leveraging data analytics, fostering inter-provider collaboration, and prioritizing staff education as among the top ways to beat the challenges.
— Skilled Nursing News, March 8, 2024
Medicare Advantage is bad for patients and bad for investors
In 2023, enrollment in Medicare Advantage, the version of Medicare run by private insurers, surpassed 50% of eligible beneficiaries for the very first time. Investors in MA insurance companies experienced a rude awakening in late January, with insurer stocks plummeting in the face of earnings reports showing profits falling far below expectations in the last quarter of 2023. Companies like CVS Health and UnitedHealth Group saw losses of 5.2% and 6.2% respectively, while Humana, whose business model relies heavily on the MA program, fell an astonishing 14.2%.
— STAT, February 28, 2024
An insider’s guide to managed care contract exclusions
There’s a key question more providers need to know the answer to: What is a contract exclusion? A contract exclusion details the medications and treatments that are not included in the levels of a managed care contract. If we identify and capture these exclusions and bill the health plan for them, then exclusions are great. If we are unaware of the exclusions or are unable to identify them, then they’re not so great.
— McKnight’s Long-Term Care News, December 18, 2023
Class action suit targets Medicare Advantage insurer’s use of AI to end rehab stays
Two skilled nursing patients filed a class action suit against Humana Tuesday – alleging their Medicare Advantage benefits were cut prematurely short because of Humana’s wrongful reliance on artificial intelligence. The lawsuit alleges that Humana regularly overrides clear post-acute care needs and the recommendations of doctors in order to cut costs. “This putative class action arises from Humana’s illegal deployment of artificial intelligence (AI) in place of real doctors to wrongfully deny elderly patients care owed to them under Medicare Advantage Plans,” the suit states.
— McKnight’s Long-Term Care News, December 14, 2023
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