3 Tips for Navigating the Medicare Advantage Shift

Adapting to Change: Essential Strategies for Home Health & Hospice Providers in the Medicare Advantage Era

The Medicare Advantage (MA) landscape is rapidly evolving, presenting both challenges and opportunities for home health and hospice providers. In 2023, 30.8 million people enrolled in a Medicare Advantage plan, accounting for more than half, or 51 percent, of the eligible Medicare population, and $454 billion (or 54%) of total federal Medicare spending (net of premiums). The average Medicare beneficiary in 2023 has access to 43 Medicare Advantage plans, the largest number of options ever. More than half (51%) of eligible Medicare beneficiaries are enrolled in Medicare Advantage in 2023.

Here are three vital strategies to effectively navigate the Medicare Advantage shift for home health and hospice providers.

1. Understanding and Adapting to Patient Demographics and Needs

Key Metrics:

• Health Status: 43% of MA home health users describe their health as "poor" or "fair."
• Chronic Conditions: Nearly 45% of MA home health users have five or more chronic conditions.
• Mental Health: A greater proportion of MA home health users also have severe mental illness compared to traditional Medicare home health patients, though both cohorts were similar in their ability to perform activities of daily living, according to the report.

Strategy:

Providers should gear up for more complex care management, considering these demographics. Tailoring care plans to address the specific needs of this population is critical for effective service delivery.

2. Tackling Access and Coverage Challenges in MA Plans

Key Metrics:

• Coverage Barriers: 48% of MA beneficiaries cite their health plan’s coverage as a major barrier to care.
• Cost Concerns: Around 28% of MA beneficiaries report cost as a significant barrier to accessing care.

Strategy:

Understanding and navigating the nuances of MA plans is key. Providers should enhance their communication and negotiation strategies with MA plans to overcome coverage limitations and address cost-related concerns.

3. Leveraging Experts with AI-driven Tools and Analytics

Enhanced Strategy:

Streamlining Complex Processes:

• Automated Solutions: Services and AI-driven tools and analytics provided by Prochant are not just beneficial but essential in today's healthcare environment. Prochant becomes an extension of your revenue cycle management team handling the increased volume and complexity of eligibility checks and prior authorization processes. By automating these tasks, Prochant significantly reduces administrative burdens, allowing providers to focus more on patient care.
• Prior Authorization Management: With 40% of denials attributed to prior authorization issues, bolstering this aspect of your operations is crucial. AI-driven tools can preemptively identify potential denial triggers, streamline the authorization process, and keep track of changing payer requirements.

Making Data-Driven Decisions:

• Analytics for Trend Analysis and Optimization: Utilizing advanced data analytics is key in understanding evolving trends, particularly in the context of Medicare Advantage's impact on home health and hospice services. Providers can leverage this data to optimize care delivery, enhance financial management, and predict future trends, which is vital for strategic planning.
• Addressing Revenue Impact: As Medicare Advantage continues to grow, the accompanying increase in denials and authorization complexities can significantly impact revenue. Analytical tools can provide crucial insights into operational areas that require adjustments to mitigate these financial impacts.

Addressing Industry Challenges:

• Navigating the Persistent Challenges: The Medicare Advantage shift is not a transient phase; it’s a fundamental change in the healthcare landscape. The increased need for prior authorizations and the higher rate of denials are here to stay, making it imperative for providers to adapt and strengthen their operational strategies using AI-driven tools.
• Bolstering Teams: Alongside technology, human resources also play a critical role. Enhancing the training and capabilities of the intake and authorization teams in tandem with technology implementation can provide a comprehensive solution to the challenges posed by the Medicare Advantage shift.

The shift towards Medicare Advantage represents a significant transformation in the home health and hospice industry. By comprehensively understanding the changing demographics, addressing access and coverage issues head-on, and leveraging experts with advanced technological solutions, home health and hospice providers can navigate this new landscape effectively. These strategies will not only ensure compliance with MA requirements but also support the delivery of high-quality, patient-centered care in this evolving healthcare environment.

If you are interested in learning about Prochant’s intake, billing, or collections solutions, connect with us here today.