Meeting the Needs of Medicare Advantage Organizations (MAOs)

When you talk to providers in the post-acute care field, you will hear many opinions about working with Medicare Advantage Organizations (MAOs). Some are very positive – that the MAO is funding non-hospice palliative care and working to support home-based care, including paying for non-clinical services. Some are very negative – that reimbursement can be delayed and lower than the CMS rates, and there is a great deal of added administrative burden. The truth is probably a bit of both. While many MAOs are innovating to provide more home-based, proactive care opportunities, contracted rates are often lower than CMS rates and reporting requirements are higher. 

So, where does this leave those caring for the seriously ill? Is it worth the burden to work with a MAO? The reality is that, for some providers, they may not have a choice if they want to maintain a certain level of relevance within their healthcare continuum. CMS is fully committed to having all Medicare beneficiaries in a value-based arrangement by 2030. While some of these arrangements will not be Medicare Advantage (Accountable Care Organizations and other alternative payment models are value-based), at present over 50% of Medicare beneficiaries are enrolled in a MAO and that percentage will be increasing. And VBID, the inclusion of hospice coverage within the MAO purview, is also expanding while the ability for MAOs to exclude coverage for non-networked providers will be in place by 2024. For providers not networked with the MAOs and ACOs in their markets, their referral pools may well shrink or dry up entirely. How does the hospice meet the needs of a MAO? According to MAO insiders, MAOs are looking at hospices’ CMS Care Compare and CAHPS ratings, the capacity of the organization, and the diversity of service lines. Hospices will need to negotiate rates which they have not had to do with CMS. To do this successfully, hospices will need to have a tight handle on care delivery costs and the value of outcomes, with solid data to back these up, as well as high rates of billing claim debt collection. Billing and clinical documentation processes will need to be rock solid, as will be the ability to manage claim denials. These are all dynamics that most hospices have not had to manage until now, but to stay relevant these will be skills that they will need to learn.

Source Material:

“Quality Data, Cost Control: Hospices’ ‘True North’ in Medicare Advantage” by Holly Vossel, posted by Hospice News on August 16, 2023, and accessible at https://hospicenews.com/2023/08/16/quality-data-cost-control-hospices-true-north-in-medicare-advantage