Home Health in the Medicare Advantage Maze: A Balancing Act

The Rise of Medicare Advantage

Enrollment in Medicare Advantage is growing much faster than expected, creating a steep learning curve for home health agencies tasked with negotiating lucrative contracts, navigating claims denials, and meeting confusing billing requirements.  
 
Although Congressional Budget Office projections expected MA plans to cover more than half of all Medicare beneficiaries by 2030, that mark was already exceeded in 2024, with 7 of every ten new Medicare beneficiaries opting to enroll in MA.  
 
The Centers for Medicare & Medicaid Services (CMS) reports that over 30 million people are enrolled in MA plans. Private insurance companies offer these plans and typically provide additional benefits beyond traditional Medicare, such as vision, dental, and hearing coverage. 
 

The Challenge: Navigating a Complex Medicare Advantage Maze 
 

While MA plans offer a wider range of benefits for seniors, many healthcare providers, particularly home health providers, are facing significant challenges due to the intricate administrative processes involved.  

 
Some providers have been unprepared for the increased claims processing and quality review burden associated with MA plans. Verification and document management tasks and the number of MA beneficiaries have considerably increased at most agencies.     

 
Here’s a breakdown of other key MA hurdles: 
 

• Confusing Contracts: MA plan contracts can be lengthy and convoluted, making it difficult for providers to understand coverage details and reimbursement rates.  
   
• Increased Workload: At intake, providers must sort through multiple sets of rules and requirements for various plans to determine the patient’s eligibility for various services.  Some MA plans offer a portal to streamline the process, but many do not.  
   
• Shorter payment timeframes: While traditional Medicare claims may have allowed up to a year for claims to be paid, MA plans generally have shorter times, increasing pressure on billers to expedite claims processing.    
   
• Denial of Claims: Providers report high rates of claim denials from MA plans, often with unclear reasoning. Appealing denials adds another layer of administrative burden. 
   

Looking Ahead: Potential Solutions for Streamlining MA Burdens 

The future of MA plans hinges on finding solutions to streamline these administrative burdens. Here are some potential areas for improvement: 

• Standardization of Contracts: Standardizing contracts across MA plans would make it easier for providers to understand coverage and streamline the billing process. 
   
• Streamlined Prior Authorization: Implementing electronic prior authorization systems and establishing clear timelines for approvals would reduce delays. 
   
• Transparency in Denials: Clear and specific reasons for claim denials would allow providers to address issues more efficiently. 
   

How SimiTree Can Be Your Guide 

At SimiTree, we understand the complexities of Medicare Advantage and the challenges it presents for home health and hospice providers. Our team of experts can help you navigate the ever-changing landscape of MA plans by providing: 

• Contract Review and Analysis: Ensuring proper reimbursement requires more than negotiating rates. SimiTree’s financial consultants can help you establish your organization’s value proposition and explain the intricacies of your MA contracts. When rates can’t be negotiated, other benefits can be added to an MA contract, including more beneficial payment processing timeframes. 
   
• Intake Support: Establishing efficient processes with built-in communication time points, setting up an effective payer matrix, and streamlining workflow. 
   
• EMR optimization: The right adjustments go a long way. Customizing and optimizing technology to ensure crucial reporting can ease the burden of processing MA claims. 
   

• Claims Management: We can help you manage your claims and appeal any denials you receive. 
   

By partnering with SimiTree, you can streamline your administrative processes, maximize reimbursement, and focus on delivering quality patient care. Learn more about SimiTree’s services at www.simitreehc.com. 

Want to learn more?  

Check out our article on 12 Tips for Negotiating Medicare Advantage Contracts. 
 
Watch these helpful webinars on our Webinars page under the Consulting tab: 

• “How to Win the Medicare Advantage Market” 
  Presented by Rob Simione, SimiTree SVP, Consulting, and Jonathan Dickinson, Senior Manager, Financial Consulting   
• “Unlocking the Potential of Medicare Advantage: A Webinar for Home Health Financial Growth” 
  Presented by Brian Harris, Vice President of Financial Consulting