Managed Care Contracting Made Simple

In the past, it was not uncommon for a DME supplier’s payor mix to consist entirely of Medicare and Medicaid fee-for-service (“FFS”).  However, this is no longer the case.  The market is more competitive than ever, and industry initiatives such as competitive bidding has forced suppliers to expand their payor mix.  Today, about 35 percent of Medicare patients are on Medicare Advantage Plans, and about 70 percent of Medicaid patients are on Medicaid Managed Care Plans.  These percentages are increasing.  This program will discuss the challenges facing suppliers as they enter the managed care arena, including (1) the refusal of a Managed Care Plan (“Plan”) to allow new suppliers on their panels; (2) coverage and reimbursement policies that are different than FFS programs; (3) the prohibition against selling cash items to “covered lives” under the Plan; (4) a “take it or leave it” attitude by the Plan; and (5) Plans entering into “sole source” and “preferred supplier” arrangements.  Equally as important, the program will discuss the steps that suppliers can take to overcome these challenges.

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