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A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
A SNF Operating Model for Managed Care Success
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A SNF Operating Model for Managed Care Success

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  • 1. A SNF Operating Model for Managed Care Success April 23, 2009 Dava Ashley, VP Operations West – Covenant Care Jerri Ollett, MPA HealthCare Strategies
  • 2. Managed Care Success
    • First-get a contract
    • Prepare for utilization
    • Clinical preparation
    • Billing
    • Controlling expenses
    • Proactive operations
    • Market for increased volume
  • 3. Contract Terms
    • RUGs
    • Percentage of RUGs
    • Levels
    • All inclusive rate
    • Bed reservation
    • Volume based rates
    • Capitated
  • 4. 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
  • 5. 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
  • 6. 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
  • 7. 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
  • 8. 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
  • 9. 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
  • 10. 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
  • 11. Contract Success
    • Consider a case manager
    • Physician coverage
    • Know the contracts
    • Managed Care Triple Check with Contract Manual for reference
  • 12. 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
  • 13. Contract Success
    • The 5 W’s
      • Who is the plan
      • Who is the payor
      • Where are the claims sent
      • Who authorizes care
      • Which contract is being used
  • 14. Prepare Your Organization for Managed Care
    • Clinical Systems
    • Billing Systems
    • Expense Control Systems
  • 15. 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
  • 16. 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
  • 17. 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 t herapy terms in the contract
  • 18. 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?
  • 19. 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
  • 20. 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
  • 21. 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
  • 22. 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
  • 23. 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 MCO’s work
    • Assure that you have physician coverage for each contract
  • 24. 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
  • 25. 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 won’t have as much time to really get to know the patients
  • 26. 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
  • 27. 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
  • 28. MCO’s 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
  • 29. MCO Expectations
    • Looking for results
    • Clear concise communication
    • Discharge planning early in stay
    • Satisfaction surveys good
    • No bounce backs to acutes
  • 30. 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
  • 31. 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
  • 32. Conclusion
    • Managed Care is quickly coming across the U.S.
    • You can be successful with some dilligent preparation of your organization
  • 33. Questions and Answers
    • Thank you very much
    • Dava Ashley 949-349-1200
      • [email_address]
    • Jerri Ollett 707-769-7481
      • [email_address]

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