Be Prepared So You’re Not Caught Flat-Footed
Medicare Advantage is undergoing significant changes that will affect payers and providers including implementation of new Star Rating calculations designed to prioritize clinical performance and medication management over patient satisfaction scores, while also introducing a new “Health Equity Index”; to specifically reward plans that effectively care for low-income and disabled individuals. These changes will likely make it more challenging for plans to achieve high Star Ratings, potentially impacting reimbursement rates for providers.
Major shifts are coming to Medicare Part D plans including a prohibition on the collection of pharmacy DIR fees. This means that payers will no longer be permitted to claw back money paid to pharmacies for perceived performance shortcomings by the pharmacy. The lack of DIR revenue coupled with a reduction in government reinsurance payments from 80% to 20% of catastrophic costs will significantly impact plan revenues and may lead to adjustments in provider reimbursement structures.
Change #3 – Commercial Insurance
While specific changes vary by insurer, some general trends include an increased focus on value-based care models, expansion of telehealth coverage and reimbursement and greater emphasis on health plan price transparency.
How Will These Changes Impact Your Healthcare Practice?
Impact #1 – Reimbursement Pressures
The changes to Medicare Advantage and Part D are likely to put downward pressure on reimbursement rates as insurers look to offset lost revenue. Practices may need to negotiate contracts carefully and consider diversifying their payer mix.
Impact #2 – Administrative Burden
New quality metrics and reporting requirements, especially related to healthcare equity, will increase the administrative workload for practices. Investing in robust practice management systems may become necessary to keep up with these demands.
Impact #3 – Patient Mix Considerations
The shift towards rewarding plans that serve vulnerable populations may incentivize practices to focus on these patient groups. Practices may need to develop new capabilities to effectively serve and engage these populations.
Impact #4 – Technology Adoption
To meet new quality standards and reporting requirements, practices may need to invest in enhanced electronic health records and data analytics tools.
With evolving insurance panel requirements, practices should be prepared for potentially more complex credentialing processes. Staying proactive and organized in maintaining credentials will be crucial. By understanding these changes and proactively adapting, healthcare practices can position themselves to successfully navigate the evolving insurance landscape.
