In this episode, we’re pleased to welcome back BESLER’s Senior Manager of Revenue Cycle and Clinical Review Nurse, Meliza Weiner. In this episode, Meliza will share a Medicare Advantage update ahead of what she will share in an upcoming BESLER webinar.
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Highlights of this episode include:
- Medicare Advantage overview
- Enrollment trajectory
- Why we’re seeing a jump in enrollment
- Impact of COVID-19 on Medicare Advantage plans
- Tips for providers
Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome back BESLER’s senior manager of revenue cycle and clinical review nurse Meliza Weiner. In this episode, Meliza will share a Medicare Advantage update ahead of what she will share in an upcoming webinar. Thank you for joining us today, Meliza.
Meliza Weiner: Thank you, Kelly.
Kelly: Well, let’s just jump in today, shall we? Most people in the audience are probably familiar with Medicare Advantage plans, but could you give us a brief overview of what they are, how they operate, and what’s new in ’22 and maybe anything you have for ’23?
Meliza: Oh, okay. Sure. I can do that. So, Medicare Advantage and like you said, a lot of the audience are familiar with it. We sometimes call it MA. So, when you hear the phrase MA, we mean Medicare Advantage. It’s also known as Medicare Part C and it is a bundled plan offered by private companies that are approved by Medicare. These plans typically include benefits that are Medicare part A, Medicare Part B, and many times it includes Part D as well as additional coverages. Medicare Advantage is an option that’s available to all Medicare part A and B enrollees. It also includes the end-stage renal disease patients. Now this is actually a result of the 21st Century Cures Act. We’re actually now in its second year. And this actually gives people with end-stage renal disease access to any Medicare Advantage plan in their area. Prior to this change, patients that have end-stage renal disease, they were only eligible for a limited amount of plans. And now with the special-needs plan that’s part of Medicare Advantage, they can cover chronic conditions or any enrollees that are dual eligible, which is basically Medicare and Medicaid as well as any institutional enrollees. Now I think when people hear Medicare Advantage plan, they’re saying, “Well, what’s in it for me? What’s the advantages and the disadvantages?” So, I think the one thing that I want to cover is also the advantages of Medicare Advantage. One of the key advantages of MA plans is it is what is known as an all-in-one coverage for inpatient, for outpatient, and for many plans. It also includes your prescriptions and dental services. It also adds some supplemental benefits that are typically not covered by Medicare.
The benefits include many plans that have expanded their flexibility with services such as telehealth visit. They are now covering transportation, some nonskilled home services, home based palliative care services, and some home safety equipment like your bathroom equipment. They also cover vision care, over-the-counter items. And for limited time frame, they also cover some meals in there. And then there are also some additional offerings that just recently happened like outpatient mental health. This one I thought was interesting that they’re now starting to include discounted pet support medications, caregiver support reimbursement, vaccines. And the new thing now is this rewards program. I think a lot of us are familiar now with having rewards program when you go to a department store, retail stores, or restaurants. And now they’re offering rewards program as well. And I think the key aspect here when people are thinking about Medicare Advantage, the advantages to this MA plan is the premiums and the out-of-pocket expenses have become very affordable. The costs do vary depending on the plan that you take based on the state and the geography. But the out-of-pocket maximum that is set by the plan is actually more affordable. And this is typically different from traditional Medicare. So once traditional Medicare member reaches their out-of-pocket maximum, they no longer need to pay for their deductible or copay, but they do still need to continue paying their monthly premium.
Now with any plan, there’s always disadvantages. So, one of the disadvantages for an MA plan is the enrollee really needs to pay attention to the details of their plan. Unfortunately, they would think that everything is covered and not realizing that the plan that they chose, not everything is covered. And so they need to pay particular attention especially also if the monthly premium changes with Part B coverages. Sometimes with Part D as well, some of it might be covered, some may not. So that’s a disadvantage. The other is physicians. A lot of members think that their physicians are within network, but then when they choose a plan, they don’t realize that the physician is not covered. So they have to pay particular attention to that. And if they decide to keep their physician, is there going to be an out-of-pocket cost? Which could be a little bit greater than what they’re used to. Or maybe they need to change their providers this time. The supplemental benefits that I mentioned earlier, that’s an advantage. Again, that’s supplemental, which means they have to choose that and put that in their plan. So, they have to pay attention to that one. If they want the discounted pet support medication, they have to make sure that that’s covered in the plan that they chose. And then the Medicare Part D part that’s part of this plan, which is the prescription coverage, one thing that they have to make sure is that the medications that they’re taking is actually part of the prescription coverage in that Medicare Advantage plan. So, there are a lot of details, really, that they need to pay attention to it. But that’s pretty much, I think, a quick overview of what a Medicare Advantage plan is.
Kelly: Wow. That’s a lot of great information. I know I’ve learned a lot about Medicare Advantage plans just because my dad just started one. I learned something new, too. So, thank you for that. I know that Medicare Advantage plans have been increasing in popularity. What does the enrollment trajectory look like?
Meliza: Oh, my word. Kelly, the number is really increasing, really. Based on the latest information from CMS for 2021, there were nearly 26 million MA enrollees. That includes the HMO and the PPO.
Meliza: Yeah. And now it has increased to 27 million in 2022. And we’re not even done yet for 2022. And now they’re projecting that the enrollment will reach up to 31.8 million people in 2023. So, yeah, that’s a big jump. Really big jump right there.
Kelly: Yes, it is.
Meliza: The reasons really behind this increase in enrollees going for it is because of the baby boomer generation. They’re now reaching retirement age, or some of them already retired, or some went into early retirement, and they’re actually eligible for Medicare. And they’re used to commercial plans. They’re used to employer-sponsored HMO and PPO plan. They’re used to within network. They’re used to referrals. They’re used to copays and out-of-pocket maximums. So they want to stay in their comfort zone. So, they want to stay with a similar plan that’s offered by a familiar company like United Healthcare or Aetna. It makes them comfortable. They want to be in that comfort zone. The idea of this all-in-one insurance plan, who doesn’t want that? You have one plan. It covers everything. You don’t have to think about it anymore. Besides, the details that I mentioned earlier. But the expanded benefits, the low monthly premium also help. In fact, I learned that the projected average premium for 2023 Medicare Advantage plan is actually going to decrease by nearly 8% from the average now in 2022. So–
Meliza: Yep. So that’s out there right now. So now you’re going to have more enrollees going for Medicare Advantage plan. And I think the other reason why we’re seeing this jump is when you have traditional Medicare, you have to think of what’s not covered. And you want to cover what they call that gap that’s not covered by Medicare. In order to cover that, you have to go to a private company. Might as well take Medicare Advantage plan. From an enrollees point of view, I don’t have to think about the gap that’s not covered. So, I think that could be a reason for that increase. Another thing is new companies are joining Medicare Advantage arena. And then the existing companies that are already doing the Medicare Advantage plan, they’re now increasing their offerings. They’re increasing their services. Coverage, they’re increasing that. So, I think that in itself is increasing the popularity of the influx to joining the Medicare Advantage plan. United Healthcare and Humana still accounts for the largest percent of enrollment. And I believe we are looking now at 3,800-plus plans that are available in 2022. So that number is going to increase. And I think that’s pretty much– besides the expansion of services, again, I thought that if I could have Medicare Advantage plan, I’ll take it right now. That discounted pet support medication, I thought that’s pretty interesting and the rewards program.
Kelly: Yeah, a lot of that makes a lot of sense, and I can see wanting to stay in a familiar plan, so. And the growth is astounding. So that’s all great information. Meliza, what was the impact of COVID-19 on Medicare Advantage plans? Or do you see any long-lasting impact?
Meliza: You know what, it’s funny because it seems like every conversation always has to involve COVID-19, right? So COVID-19, I guess is here to stay. Are we going to say that– when it started, COVID-19 was all new and people are not familiar with it, and now it’s becoming a routine, and I think it is here to stay. We all know that. It has had major impacts to the whole aspects of healthcare as we know it. And because of that, there were a lot of programs that have been put in place that basically the focus really is for the ease of the care of the patients as well as credentialing for providers that’s going to care for the patients and also allowing our nonhospital settings to be used and to bill at different levels to take care of the patients with COVID-19. And the term hospitals without walls is another common phrase that’s being used right now as part of a program that’s helped handling that COVID-19 arena, should we say. For most Medicare Advantage patients, there really is no cost sharing for COVID related testing, treatment, or telehealth visits. As of right now, the programs in place are in place for 2020, 2021, and 2022. I have yet to see any more changes. I know CMS is taking a look at maintaining or streamlining its process now to those programs after 2022. So that’s up and coming. However, everything else is still in the same status quo. COVID vaccine will still be covered at no cost to the members. Some plans also waive cost sharing for non-COVID-related services to encourage the patients to continue with their routine healthcare services. Because I think if you remember back at the beginning when we had the pandemic of COVID-19, everything stopped as far as routine healthcare screenings. And now we’re trying to get back into that routine. And all the MA plans are encouraging that. Providers are still being offered accelerated credentialing processing as well as there were still some additional waivers and allowances that are still in place. Such as the waiving of the referrals for in-network care that’s related to COVID-19, authorization for testing and treatments for COVID-19, wavering the pre-authorization for transfers to skilled nursing facilities to any post-acute facilities as well as the flexibility for emergency services, increasing payment for COVID DRG payments, as well as diagnosis code specific to COVID screening and treatment.
Kelly: Okay. So, yeah, it definitely sounds like it’s going to be around for a while and definitely has a long-lasting impact. Do you have any tips for providers as many are likely to see increases in their Medicare population over time?
Meliza: Yes, I do. And I think my tip is going to be similar to what we’ve been providing as tips is to just stay on track, stay on focus. And like you said, because it is growing and we’ve seen the numbers, we know what the numbers are going to be like. I think the one thing that providers really need to pay particularly careful attention to is the contracts. When they’re writing their contracts, they have to be very careful with those contracts. Back in the day, Kelly, the MA contracts were just an addendum where they slap it into a commercial contract that they have and just don’t pay particular attention to it. Well, now I think they need to pay particular attention to those contracts. These contracts need careful scrutinizing. You need to evaluate it really well. MA plans have to follow Medicare rules, and some really kind of tweak it to kind of make it vague. But in essence, really, because they are under the Medicare guidance and payment through Medicare, they have to follow Medicare rules. So, providers need to be careful with their contracts, especially when it has something to do with payment methodology rules. The language itself has to be scrutinized between methodology versus the actual rates, the timely filing, the prompt payment, add on payments. They need to be closely examined. The other thing that they also need to take a look at is opportunities that create value-based or risk-based payment models. Medicare Advantage plans sometimes also, they seek to help the patients to be healthier. Which I think as providers, it creates an opportunity to work with their contracted MA plans to create awareness and education through marketing of services and offerings, and I think that’s going to help as well.
It is also, I think, important, I think, for providers to verify the coding of claims. I think that’s one of the things that they forget a lot. I wouldn’t say forget but kind of put it in the low priority is that the coding of claims that are falling under COVID-19 related services. They have to be careful with that and make sure that they have the right codes and the backup documentation for that in order to receive payments. Following positive test requirements for additional DRG reimbursement using the correct diagnosis or CPT codes for stays, telehealth visits, testing supplies. I mean, in essence, really, providers really have to pay attention to their coding, especially now when it has something to do with new diagnosis such as COVID-19. And I think one key feature that a lot of providers seem to not realize is that providers, they get audited but so are the MA organizations. They are subjected to audits as well. So I think the one thing to keep in mind is that when the MA organizations are audited, they’re also audited and conducted by the OIG, which is what’s also auditing the providers to determine the health status of their enrollees and the MA organization’s compliance with its participation with CMS. So that’s something to keep in mind. In fact, I’ve learned that to date, the audits that were conducted recently demonstrated numerous, numerous miscoded diagnoses resulting in net over payments valued in the millions. So, if that alone is showing a lot of miscoded diagnosis, that’s something that the providers can also take a look, not just because of the MA plans but also for themselves about coding.
Kelly: Wow, those are a lot of great tips. Thank you so much. And thank you so much for joining us today, Meliza, and sharing your Medicare Advantage knowledge with us.
Meliza: Oh, you’re welcome. And thank you for the invitation, Kelly.
Kelly: And you can learn more from Meliza and her colleague Olga on Wednesday, November 9th, at 01:00 PM Eastern Time. They’re going to do a webinar that will dive deeper into the Medicare Advantage world. So, feel free to learn more about that on besler.com. And thank you all for joining us for this episode of the Hospital Finance Podcast. Until next time.
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