Andrea Stark on re-engineering Medicare Advantage

YARMOUTH, Maine – There will be overdue changes to Medicare Advantage in the next year that will make them “a lot more friendly” to HME providers, says Andrea Stark. 

Stark, a Medicare consultant and reimbursement specialist with MiraVista, joined the HME News in 10 podcast in August to take a deep dive into the “state of the state” of Medicare Advantage and what’s in store for these plans. 

Here’s an excerpt: 

‘State of the state’ 

“There has been quite a buzz on Advantage from several fronts. We set a new record this year for the tipping point on Medicare enrollment being over 50% Advantage compared to those in the fee-for-service program. I feel like a little bit of the luster is wearing off, though. There’s been a lot more attention from the OIG (and) more attention from CMS. We (also) had pretty big news, where the Humana MA plan adopted a single-source contract in each state, with a few exceptions, with AdaptHealth and Rotech.” 

 The single source/bid comparison 

“We have precedent for FFS. When they went to competitive bidding, I thought it was telling that CMS focused on 130 of the largest metro areas – areas where providers can compete, areas where the beneficiaries are. Humana did not exclude rural areas, didn’t go after just the metro areas, and (didn’t) carve out products. Under bidding, we also had a standard where no single supplier could have more than 20% of the market. (However), there is a concept in the MA plan program materials that refers to network adequacy. These plans have an obligation to ensure there’s not going to be disruption to patient service…and they have enough contracted suppliers to service the beneficiary population.” 

Rumbles of change 

“CMS has put together a final rule that’s going to be revamping MA plans, specifically the prior authorization program. One of the biggest things (in the final rule) is a mandate from CMS that Advantage plans can’t impose prior authorizations for a period of 90 days, if there are changes in insurer and (the patient) has active service. So, for 90 days, if a patient comes onto a new plan, the plan can’t impose prior authorizations, nor can they impose network requirements or exclusive networks. I’m really excited. That is a huge change to ensure that we have no gaps in coverage.” 

The future 

“I think the MA plans are going to be making some overdue changes. They’re going to become a lot more friendly to DME suppliers, looking at (recent) trends. I don’t think the DME community opposes prior authorization, but we want to know when our services are going to be approved. We want the MA plans to follow fee-for-service. If they do that, I think we can play very well with each other. I think DME is an extremely valuable partner to these Advantage plans, but we have to make sure not only they play by rules, but also there’s profit there. Some of these rates are going to have to come up.” 

To listen to Stark and other industry movers and shakers, visit our podcast page.