Stark and Baird on what’s critical to a provider’s livelihood

YARMOUTH, Maine – Medicare Advantage will be the elephant in the room in 2023, say Andrea Stark and Jeff Baird, due to the “sheer mass migration” of beneficiaries to these plans. 

“Everything is centered around managed care,” said Baird, chairman of the Health Care Group at Brown & Fortunato. “It seems like, overnight, we woke up and 50% of Medicare patients are now covered by these plans.” 

HME News connected with Stark, a Medicare consultant and reimbursement specialist at Mira Vista, and Baird ahead of their “Look Ahead” webcast* in February to talk about what issues to keep an eye on in 2023 and why the annual event is one of their favorites. 

HME News: First, let’s talk about what surprised you most in 2022. 

Stark: The biggest surprise ties back to 2021 but was really rolled out in 2022: the oxygen expansion. Getting rid of certificates of medical necessity (CMNs) retroactive to the start of the pandemic is really transformative. It basically undid 30-plus years of precedent from a reimbursement policy standpoint and has the greatest potential to reduce days sales outstanding. 

HME News: Looking ahead at 2023, what’s the biggest challenge? 

Baird: I’m focused on Medicare Advantage and, in particular, the vertical integration that’s happening. I use, as a parallel, pharmacy benefit managers (PBMs) in the pharmacy and specialty pharmacy space. They’re the middlemen and they exclude most independent pharmacies from being on their panels, and we’re starting to see the same thing with Medicare Advantage and DME, with, for example, Humana buying onehome. That could have a really negative impact on the supplier. 

Stark: I’m going to dovetail on that. The focus for suppliers needs to be to know their rights and where they can push back. They need to know what Medicare Advantage plans must be held accountable to when it comes to reimbursement and coverage policies. The OIG has confirmed what suppliers have suspected all along: These plans follow fee-for-service, but in reality, they depart from it more than they follow it. Holding them accountable is critical to suppliers’ livelihood. 

HME News: What’s your general go-to advice for providers trying to navigate the ups and downs of any year? 

Stark: I think it’s coming down to automation and efficiency, to the extent that suppliers can harness some of the benefits of their billing platform to do more with smaller staffs and less resources and prevent problems on the front end. That’s going to be an ongoing theme. 

Baird: This is self-serving, but it’s important for suppliers to proactively run ideas through a health care attorney so we can keep them from stumbling. It used to be, when a supplier found out they did something wrong, they could correct it and not worry about the past, but that’s no longer the case with the 60-day rule and six-year lookback. 

HME News: What makes your annual “Look Ahead” so fricken enjoyable? 

Stark: There’s just a great banter back and forth. To have these two spheres of expertise – legal and reimbursement – you can cover a topic from multiple perspectives, and it’s a much richer conversation and exchange of ideas. 

Baird: I love the give and take. We know what we’re talking about, and we know what we don’t know. Of everything I do, this is the most fun. 

• Register for the “Look Ahead” webcast here.