Home Care U - Demystifying the Deep Dark World of Third-Party Billing (Greg Bean Pt. 2)

Episode Date: July 31, 2023

Third-party billing is one of the most technical, opaque topics in home care—yet it's a critical part of business growth for thousands of agencies. We've found one of the industry's leading experts on how the various types of third-party billing work and he's giving a masterclass on moving into Medicaid billing, long-term care insurance, Medicare Advantage, and more.Enjoying the show? Send me a text and let me know!Learn more about Careswitch at: careswitch.comConnect with the host on LinkedIn: Miriam Allred This episode was produced by parkerkane.co

Hey, welcome to Home Care U, a podcast made by the team at Care Switch. Nobody went to school to learn how to run a home care agency, so we're bringing the education to you. Join our live audience by going to careswitch.com slash homecareu or listen on your own time wherever you get your podcasts. Home Care U is hosted by myself, Miriam Allred, and Connor Koons of CareSwitch. Enjoy the session. Welcome, everyone, and thanks for joining us again live today for Home Care U, U4 University. I am Miriam Allred with CareSwitch. I'm excited to be back in the interviewer driver's seat today.

It's been a couple of weeks for me, but I'm excited to be back and particularly excited for this long-awaited second session with Greg Bean. Before we jump in, I just wanted to do kind of a quick shout out that I don't normally do, which is thanks to all of you for listening to the show. I've gotten a few emails or DMs this past week about how influential this podcast has been in your growth and in your business growth. And so I just want to say thanks for trusting us and giving us the time and listening to this show. We really do hope that it's been helpful to you and your business. And like you've discovered here, we like to go deeper on home care topics than you can find elsewhere in the industry.

There's unfortunately too much fluff out there these days. And so we try and bring on the best of the best to give you the most up-to-date, accurate, in-depth information that you can find anywhere else. So if you like what you're hearing, shoot me an email, miriam.careswitch.com or jump on wherever you're listening to the podcast, Spotify, Google, Apple, and leave us a review. It helps us know that we're headed in the right direction. And also, if you have suggestions for topics, we're all ears. We try and keep a pulse on what's happening and where, you know, the puck is headed. But if you've got other ideas of topics and guests that you want to see on the show, you know, don't hesitate to throw those our direction as well. So without further ado, today, we're finally back with the very busy, fan favorite, world traveler, Greg Bean, Vice

President of Paradigm Senior Services. That is ParadigmSeniors.com if you're less familiar with them. They help with literally the full gamut of third-party billing for home care agencies. And in my humble opinion, Greg is a walking encyclopedia for third-party billing. And so many of you have been asking us, you know, when is the second session? When are we covering Medicaid? When are we covering Medicare Advantage? And that's exactly what we're going to do today. So Greg, before we deep dive, why don't you take a couple of minutes and introduce yourself and introduce,

you know, your background and some of your career highlights in home care. Thanks, Miriam, for allowing me to jump back on and speak with you guys. It was a great experience last time here. Hi, everybody. I'm Greg Bean. I have been working in the home care space since 1985. Actually, I started in the acute care space in 1985 and spent about 10 years working in critical care, critical care, nursing, lifelight, emergency care, moved over to the home care space in the mid 90s, have had the opportunity to actually open a couple of home care companies, have worked for companies like Bayada, PSA Healthcare, Visiting Angels, and now work with Paradigm Senior Services to assist as kind of a product expert with all of our home

care needs. So you know, what we're talking about, you know, at that 30-foot view, but also on the ground floor, which is why I think your knowledge is so vast. So thanks for being here, and thanks for that quick introduction. Let's go ahead and just jump right into it. So to make sure we're all on the same page, today we anticipate covering Medicaid and Medicare Advantage. In the previous session with Greg, we did a deep dive on VA billing. And so know that you can go back and reference that episode if that's where your interest lies. But today, we're going to cover Medicaid and

Medicare Advantage. So before we kind of tackle a variety of topics, Greg, you were just telling me a lot is happening on this front of Medicaid and Medicare Advantage. There's been a lot of initiatives and movements and push for it over, honestly, probably the past decade, but we're finally seeing some more traction and momentum. So just kind of start there overviewing the landscape of these payer sources and what's coming out of this territory. I'll jump in. I'll do Medicaid first. We'll talk a little bit about Medicaid. One of the amazing parts about Medicaid is Medicaid's broken up into different buckets, and they have long-term supportive services for both adult, pediatric, and then they throw

long-term supportive services into nursing homes, so on and so forth. But in the adult space, last year for long-term supportive services, which is your waiver programs, your straight Medicaid for hourly care long-term, the budget was $166 billion in the United States. And then what we saw is a 16% increase year over year going into 2023. So when you look at the funding for Medicaid programs for long-term supportive services in the home care environment, that number has pushed up to almost a quarter of a trillion dollars in funding. So there's, and we're seeing a significant amount more hours and time associated with the ability to provide services. On the opposite side of that, with Medicare Advantage, in the past, Medicare did not pay for any home health aid services other than for bathing or when you had a specific skilled need. They moved away from that with Medicare Advantage and CMS no longer mandates that they have a skilled need to receive home

health aid hours. So typically those hours were still short. They weren't a lot of them. And in 2022 or in 2020, when they started rolling out these programs, there were 207 programs is all there were in the entire country that were actually offering private duty home care services with Medicare Advantage. In 2022, there were 1,091 health care plans offering home care services for private pay, private duty, without having to have a skilled need. So we're seeing an incredible increase. The rates have come up, the services have come up, and we can touch on rate specific and some of the state rates and what's going on as we move through the conversation. Awesome. Well, thanks for that quick overview. I think that just kind of gives us a lay of the land

and knowing that things are getting better. You know, all the time and attention and advocacy in this direction hasn't gone unnoticed and we're seeing some momentum there. So that's great. So let's start with Medicaid. I wanna spend probably 20 to 25 minutes on each of these, but let's go kind of all the way down the Medicaid path and then we'll jump back and go all the way down the Medicare Advantage path.

So let's zoom out and first talk about Medicaid as a service line for a home care agency. On the line today, we probably have some agencies that are just billing private pay. We may have some that are kind of tapping into VA or long term care, et cetera. But who is Medicaid a right fit for? Which home care agencies should be considering Medicaid as a new payer source for their business? So I think you have to look at a couple of different factors when you're looking at Medicaid being a good service line for you. For instance, if I was in North Dakota today, they typically see 20 to 40 hours a week of service being provided under

this platform. It can be provided by a family caregiver and their reimbursement's $38 an hour. So I would jump all over it. Some people would say, well, Texas is a horrible model because Texas reimbursement's only $14 an hour. But with that being said, in Texas, it's a family caregiver driven program. And Texas minimum wage is significantly lower. So they're still actually paying about 50% margin to their caregivers, and they're offering tens of thousands of hours. So we still see a massive, there's over 3 million people in Texas receiving long-term supportive services under these programs. So if you still have a 50% margin and your money's still coming in and it's significant, you don't always want to look at just how much money per hour is

the client being paid, but what are you paying caregivers? Because in the Medicaid platform, 46 of our states now allow for family caregivers to be the provider of care so you can hire the family caregiver they're usually and typically paid at a lower rate whatever your state minimum wage is and they're providing 40 to 60 hours a week for a client under those platforms so it drastically changes the landscape of the caregivers that are providing the care, the cost of providing the services, and then where you would go. So I would say, I don't believe there's a state or an agency where it's really a bad model in today's world. I think you have to look at the hours of service, the type of care being provided.

And then typically in the past, we always had longer revenue cycles and people said, I don't get paid for ever and ever and ever. We now see a lot of the states have moved over to a managed platform. So we're seeing this still, we're seeing a two-week revenue cycle where people being reimbursed in two weeks. So it's changed drastically. I think it's much better. I would actually say, I don't think there's a bad state, but you have to think about where does it fit into your revenue cycle? Is it that 35% margin in your region where you're going to carry a certain amount of hours? So maybe it's 10% of your revenue cycle, or is it where it's 50% and maybe you want 50% of your revenue cycle

within your agency. But I think it fits in a limited and or maximized scale in every single state. Got it. And so it sounds like if I'm understanding right, you know, you need to take a hard look at the requirements for your state and then identify, is this going to work for your business model and your, you know, growth trajectory? You know, it's like you need to consider all these factors and then look at it from the state level and then decide, is it a right fit for your business? So you referenced a couple of different things, hours of service. So if I'm understanding right, the length or the number of hours varies by state. Is that kind of typically in the 20 to 40 hour range that you

mentioned, or is that range vary even more drastically by the state? It varies by the state, but we do see a significantly increased number of hours over your other third-party cycles. So, for instance, with the VA cycle or with the Medicare Advantage programs, there's a more limited number of hours, whereas Medicaid has a much higher under their waiver programs and under their state managed programs, there's a much larger revenue cycle and or more hours of service. The advantages of this are like huge retention. They have a, you're retaining more caregivers because you have full-time work. You have work available.

You have a continual client flow. Clients come on and they stay for a long time. They don't rotate out rapidly. So you have long-term clients with lots of hours and you have consistency for caregivers to have work. So do you typically have a lower margin of payment? Yes. I mean, I think I would go to a specific scaled comment from a home care owner in one of our states a couple of years ago that said, you know, my margins are only at about 34%, but I'd rather have 34% of 5,000 hours a week is what I'm billing over 50% with only 500 hours. So I think when you look at it from that perspective, the hours are up,

the client flow is up, the funding is there for the programs. So I think that the model is one that I would still look at when I was providing services. Thanks for calling out that specific example, because I think that helps like paint the picture of the value and the benefits of going down this path. And in a few minutes, we'll get to probably the cons because there are some and that it's not easy and there's audits and all sorts of things. But I appreciate you calling that out. Two more things that I want to hit on. You're referencing like types of care. So to be clear with Medicaid, are there specific types of service or types of care that are provided underneath this source? Yeah. So there's there's behavioral health. There's medical need, there's developmental disabilities.

There's multiple different levels and multiple different waiver programs within these. But what we're typically talking about is the non-skilled environment. It's the homemaker, the home health aid, those type of services are what we're typically talking about under these programs. There is some habilitation and some other specialties under those that have a little higher billing rates and some other services. But typically, they're a little bit more limited hours than the other services being provided. Okay, that helps. I just wanted to clarify that as well. Let's talk about reimbursement rates. You were referencing a couple of different states. And like you mentioned at the beginning,

we're seeing an increase in a lot of states and it's slow going. I think everyone wishes rates were up in every single state and that's unfortunately not the case. But give me kind of the lay of the land from like a national perspective on reimbursement rates and then maybe calling out five or 10 states that are noteworthy to make mention of. Right. So we see over the past few years, some pretty dramatic increases. So and again, there might be a little bit of a raise or a little lower. So if I'm not specific and somebody comes on and says, oh, you were 50 cents off, I apologize. But Oregon, I believe, is just short of $38 an hour. North Dakota is at $35

and some change. Indiana just got a 33% increase. They're going to $36 and some change. Colorado just got a big increase. They're up to about $35 an hour for their services. I think there's 12 states now that are actually over $30 an hour on their base rate for Medicaid. So we are seeing an increase in the number of, in the dollar amounts associated with care, but we aren't seeing a decrease in the service provided even with those increases in the rate. So I think that, you know, as the caregiver wage is being driven up, as the minimum wage is being driven up, I do think we're seeing an increase in state rates to manage and adjust to that through lobbying and other things going on.

Georgia just got a $5 and some change raise in the spring. So again, we're seeing states raise their rates. Like I said before, everyone wants to know what their state rate is and if it's going up or down. And so I appreciate you just giving kind of a high level overview. And on the whole, reimbursement rates are going up. And that's what we want to see. And that's what providers are aiming for.

You know, I see Amber here jumping in the chat asking about California's state rate specifically. Paradigm has spent a lot of time putting together a resource that actually shows all of the state Medicaid rates. And so I just dropped in the chat the link to that. Greg informed me they update this about monthly. And so know that it's probably the most up-to-date information that you can find out there from a national perspective. But if you're interested in seeing what your state's rates are, that's a tongue twister, go ahead and use that resource that Paradigm has put out to

look up your specific rates. Greg, anything that you want to add on that tool specifically? The thing I would recognize in the tool is it's very extensive. It goes through multiple different levels. It goes through all of the state programs. Some of it is broken out by 15-minute units. Some of it is broken out by hour. But in that tool, there's a link to the state site that brings up current rates, current requirements for Medicaid within the state. So not only does it give you the base rates to the best of our knowledge, but it takes you to the site in case there's updates or changes, program requirements, licensure requirements, all of those things are built into the tool so you can go take a quick look. Awesome. Thanks for adding that. So hopefully

everyone can take advantage of that resource. I share this probably on a weekly basis because everyone's asking, you know, what their rates are and you can do your own Google search, but here is kind of a comprehensive, you know, place to go for all of the answers. So one other thing that I wanted to ask about rates, you were talking about these increases that have taken place. I'm curious, most likely rates happen when, you know, there's a push in that state and there's advocacy and there's people doing their due diligence. Beyond that, are there rate changes every year? When do these rate changes happen and why? Typically through advocacy, we're seeing the increases and the changes. We don't see a real consistent state by state, oh, 3% year over year, 5% or 9% or 12%. I mean, I have seen states that haven't had increases in 12 years. advocacy, pushing back through your state organizations, through congressional leaders. You know, I would tell everybody, you should know your local congressional people in your state.

You should be having conversations about the services being provided, about the challenges, especially when you're talking about rates, because the funding is there. The problem becomes when you think about it, there's a quarter of a trillion dollars put out there, a quarter of a trillion into these programs in long-term supportive services. This is not just monies that are paid over to Medicaid for all Medicaid services and doctor's visits and hospitalizations. That's long-term supportive care for adults. That's not even talking about the 130 billion, which is placed into pediatric care for long-term supportive services. So, you know, the money and the funding are there for them to pay an appropriate wage and a living wage

and a reimbursement so that we can pay a living wage to caregivers to support the services to these clients. Okay. Going off script here slightly, I'm curious on maybe your personal take on some of this, if you're willing to share. Home care, like we all know, and live it and breathe it is essential. And it's surprising that there's not more standardization or consistency across the country, you know, on a state by state basis, do you find there's room for improvement there or that's what we're aiming for? Or do you think it will always be this state by state fragmented model? Well, you're always going to see people combating for less regulation and people combating for more regulation. Some people want to see consistency and they feel like regulation creates consistency because someone's watching over to make sure there's increases to make sure the services are provided at specific levels. And you're going to have that same group of people that says the more they regulate, the less we get to provide and the more costs and on and on and on that goes along with that. I personally think there's a happy medium in there. I think when we have state organizations and we have the ability to legislate through them, that it helps us to look at increases because we can get the support back

through some of these organizations around licensure and some of the other things that go along. So this is a personal opinion. I think that when we've seen some regulation and some consistency, we've seen higher rates being increased in those areas. Thanks for sharing that. I was just kind of curious what your personal take is. I think I am, and maybe in a similar camp, I obviously don't have as much experience as you do, but I think there's value in consistency and the home care isn't going away anytime soon. And the numbers, we all know the numbers, there's so much demand. And so I think some version of consistency that's intentional and set by the providers themselves is the way to go, which is where the advocacy comes in. You know,

you get to like step up to the plate and decide and vocalize your opinions of how things should be structured to create most benefit for you. So thanks for sharing some of that. Let's get into a little bit of the hairier topics with Medicaid and talking about documentation and processes and technology and what it actually looks like to pull off and be successful with this payer source. Let's start with documentation and record keeping. That's kind of an open-ended question, but what does that process look like in a home care agency and how difficult is it really? I think the challenge is monitoring and measuring outcomes through, well, I'll just go right down, electronic shift verification. So the CARES Act came into play. It said that all timekeeping needed to be done electronically, and it needs to be recorded

and pushed through an aggregator or a third party through two state organizations to eliminate fraud and or not showing up for shifts and all the above. So Medicaid across the country has moved to and is mandating electronic shift verification. So the big challenge with that is with our caregiver population consistently clocking in, clocking out on time, making sure they're at the place where they're supposed to be clocking in and clocking out on a timely basis becomes a challenge for everybody. So then it becomes a nightmare from the revenue cycle because you've now had a caregiver that didn't clock out or clock in on time.

That went through to the state, through an aggregator, through the timekeeping system. And then whatever AMS or EMR or whatever you want to call your software system created a bill from their work timesheet and it sends across and the two don't match up. So we get rejections and denials and challenges and all the things that go along with that. And of course, then you fall under timely filing with 180 days. And I mean, I could go

down this rabbit hole of why having a positive system that manages this timekeeping system and then has a way to match up and create corrected, edited, consistent timesheets to keep all of those things in place leads to timely payment. So rather than dealing with rejections and having to do corrective action all the time, you're actually working it through from the front end and knowing how to manage those times and then correct those on the front end through an accurate and consistent system. I think for most people, this EVV site is familiar territory and understanding what that entails. Is there any additional documentation or legwork on the administrative side? Obviously, like the timekeeping is part of that,. Is there any additional documentation or legwork on the administrative side? Obviously, like the timekeeping is part of that, but is there any other administrative burden?

Yeah, you're keeping care notes, consistency of the actual services being provided, things along that line. And then, of course, you have to deal with state licensure and monitoring and measuring what's going on with that and credentialing that goes along with it and those pieces. And all those become barriers to people jumping into the system because they're worried about what happens when I get surveyed or does a surveyor come in? If you do everything correctly, surveys are incredibly easy. In fact, it's just an administrative person coming in to check things off and checking off the boxes and saying, well done, do a good job. If you're missing some things along the way, they'll do some corrective counseling, talking, and so on. So

if you're doing everything correctly, it should just be a learning experience. And survey is actually quite simple. And to be perfectly honest, I probably have sat through a hundred if I've sat through five. So I would tell you I've been in places where we've had more challenges than others, but typically surveys are not as overwhelming as people want them to be. It becomes more of a stress oriented with, oh my gosh, I did I do something wrong rather than look at all the things I did right. And if you're following the regulatory processes from the timekeeping all the way back to making sure that you've documented that your care plans are in place and the other things that you have going on are correct, there really is not an issue with survey. I think it's actually an incredibly simple process. Well, I'll play devil's advocate for a moment. I've probably heard more horror stories

than positive stories with surveys and audits. But it's good to know. I think to your point, it's a good exercise. And of course, your first one will be intimidating. Most likely, you will have challenges or issues that you need to resolve. And don't take that personally. It's an opportunity to grow and improve. I'm not so familiar with the process itself, but I'm assuming, you know, upon licensure accreditation, there's a very detailed list or guide of exactly the requirements that you need to follow. Is that accurate? Is there kind of like a, you know, I'm picturing like a folder of documents telling you exactly what you need to do. Is that accurate? Or what does that look like to make sure you are prepared for those processes? Every state actually has all of that

documentation requirement. So here's the challenge with it that most people fall into where they really get discouraged about surveying is you have individual surveyors from every single state coming out and doing a survey. Each one of those surveyors reads and administers policy as they read or see them with their interpretation. And I've literally seen one surveyor come in and interpret something and have a second office with a second surveyor with the same company with me there argue the point that we were doing it completely wrong and it was that that person didn't do it right and they want it done differently in weeks apart. So is there a challenge to that? Do you have to do whatever that, that I mean obviously you can dispute any finding um that comes out of a survey but for the most part you make any kind of corrective action you

move on and it's just a piece or a part of what happens within the survey process there are companies out there that assist by doing mock surveys. They have specialists that come in and actually work through what a survey is and set you up to have positive outcomes in a state-by-state basis. So you can consult with someone if you're going through these processes and you have questions about it. But again, if you follow the state guidelines when you're applying for licensure and all their requirements and the documentation that they're requiring you to have, it's actually quite simple and it's not as nerve wracking as it might sound. And again, even when they come in, you know, if they find a couple of items that you have to do corrective action for, and it's almost like, you know, if there's any surveyors on here,

I apologize, but it's almost like they're mandated to find a couple of problems because otherwise they didn't do their job. So you could be perfect and they're going to find a couple of problems because otherwise they didn't do their job so you could be perfect and they're going to find something they want you to fix so if you have a perfect survey kudos to you I I congratulate you because typically they're looking for something and then they'll find they'll you'll have an amazing office they'll find something wrong and then they're done okay I'm finished I found something that that I was able to document that you needed to fix. So it's almost like a challenge to them to find something that you need to do corrective action for. But that isn't a failure. It doesn't mean you failed your survey. It doesn't mean that something's wrong. It just

means that they want you to continue to work on your processes to do a better job. And then the agency has a specific period of time to take those corrective actions. Is that correct? Yeah. And each state mandates that number and they put it in writing. And then if it's a true corrective action, then you have to create an action plan. Usually they give you, typically it's 30 days to submit it. And then you have to submit your action plan back with what you're going to do to correct it.

And then you have to track it for whatever time frame they wanted you to track your corrective action so that if they come back to survey or if they ask you, you can show your documentation for I surveyed this many charts for this much time to make sure that they all had this piece of paper and then moving forward, whatever it might be. So those are parts of what they do for corrective action. Just to kind of round out this Medicaid segment, you've been in agencies that have billed Medicaid. I'd imagine a big component here is your staff and staff training and making sure your staff is abiding by all these regulations and documenting accordingly. Any recommendations or advice from your experience on how important it is to get your staff up to speed with these processes and making sure that's just an ongoing conversation with them? Yeah, I think, you know, having processes in place to manage and do oversight for your staff is so vitally important, but also

having whatever programming, you know, in today's world, we need to have some kind of automation into these processes to consistently take care of them and manage them and do them. But then, you know, I would use an example of these are all of us are human and schedulers want their caregivers to get paid. So they'll do lovely things like they'll bypass a freeze on a shift to pay the caregiver, even though they don't have time sheets. Time sheets aren't there, so they're not getting paid. They need to understand and really understand the idea that if they're paying for a shift or if they're billing, actually, if they're paying, they can pay for anything they wish to pay for. But if they actually drop the billing on a shift that's not provided, it's fraud. So it's bigger than just Susie not getting her paycheck on time. It's actually a fraudulent activity. And I think really driving that piece

home to understand that you're genuinely responsible for the integrity of not only your agency but yourself as well back to at a state level at a national level depending upon whether you're talking about medicare and or medicaid you you really want to make sure that it's it is a big deal that we're consistent and we do things correct. And it's actually quite easy to do if you just follow the rules. Yeah. I like the word to use like integrity. You know, I think this revenue stream isn't for the faint of heart, but if done right, you know, it can be a massive revenue stream and opportunity for your business. And I think just drawing those lines and being really clear in your communication with your employees and your staff is really important, especially as you're getting started with this, you know,

just new process in a lot of regards. So last thing on this topic, we've covered a variety of areas here. I hope this has been helpful. Any other common misunderstandings or mistakes with Medicaid that you've seen that people should watch out for? I think that with Medicaid, I would make sure that on the back end of all of these processes, billing is so critically important. Because when you start talking about the 180-day rule or timely filing or lost revenues, if you bill something incorrectly, it's not considered build. So you think you build it, it got rejected, you don't get to start over from your timeframe. So however long it took that state agency to actually kick it back to you denied, say they sat there for 90 days on their desk and they didn't send it back to you you and you're chasing around for it and you're

trying to track it and you can't figure out what's going on. Now, all of a sudden, you've lost revenue and you've lost this whole revenue chain because you waited too long to file it timely. We talk about integrity to make sure that it's done correctly in the first place, but on the back end of it, if you didn't do it correctly, you want to be paid and you want to be paid timely. So staying on top of these things for consistency, it will drive your revenue up. I've never seen an agency that consistently provided care, managed their hours, staffed their hours and billed them correctly, but lost money. People talk about losing money from Medicaid. It's usually from non-payment. If you're really looking at this and streamlining your processes and you're managing this funding source start to finish, it can be incredibly lucrative and it's consistent in the pays there.

It can be a very solid revenue stream, whether it be 20% of your business or 80% of your business or 10%, wherever you feel it best fits in your margin of activity for your overall process, whether you think private pay is going to be 80% or whatever your thought processes in the home care environment. As long as you consistently maintain those statuses, it's a consistent revenue chain that's solid that you can manage the money around. Good call outs. Thanks for adding that in there at the end, because these are these are the pitfalls that we want people to watch out for and make sure they can avoid and hearing it here and now hopefully helps them. So let's shift gears a little bit and talk about Medicare Advantage. Let's kind of zoom all the way back out here and kind of start from the top like we do with Medicaid. But talking about

Medicare Advantage, you know, what is Medicare Advantage and who is this a good opportunity for? Let me throw a couple of misnomers out there. First off, you don't have to be Medicare certified to provide care for a Medicare Advantage. Medicare Advantage is managed through a managed care organization, a Humana or one of those other third-party payers that are now being paid dollars through medicare so the way medicare advantage works is a client a medicare recipient signs their benefit over to a managed care program and that their medicare money goes directly to that program so whether it and i and i keep throwing Humana out because they're a big one that most people know the name of, but there's multiple others. So there's about 10, Cigna, some others, there's 10 that are the big 10. But Humana, I'm going to use as an example,

Humana goes into a population base and they might say, I want to take on a million clients in a geographic area. And I'm going to take on all of their Medicare platforms, and I'm not going to charge them the classic $20, 20% copay. They're not going to have any doctors copays. They're going to get home health aid services. They're going to get all this stuff passed in. There's no copays, and it's a free service, and we're only going to take their Medicare benefit to do it.

So the idea is that by taking on that million population, not everyone's going to use the benefit, not everyone's going to use the cost, and they're able to pay out these other costs along the way and still make money back. But they're mandated to pay 95% of that benefit back into services. So they're only allowed to actually pocket 5% off the top. So they have to figure out programs and pieces and parts that they can pay into on this Medicare monies to, first off, increase the visibility of their plan to have more people want to use it, but also offer more services back to the recipient within Medicare. So when CMS in 2000 said, you no longer have to have a skilled nursing need to get home health aid services, you can now give them this benefit as part of your plan. So if you need

a home health aid, they can give you whatever hours that plan wishes to do. What they initially did was kind of typically took the 120 hours that Medicare used to say what they would give you for visits per year, post procedures and so on. They just kind of pushed that same benefit under and said you get 120 hours annualized for home health aid services with a docs order. Well, that's not mandated to 120 hours. That's just kind of their base knowledge piece of it. So we've seen clients with different plans getting 30 hours a week. We're seeing them getting 40 hours a week. We're seeing them get six-month authorizations for care. It really allows people in different environments to be

contracting and understanding these benefits on a state-by-state, region-by-region benefit. So what's happening in North Texas might not be happening in Central Texas or South Texas. There might be 12 different plans, some of them offering a benefit, some of them not offering a benefit as you go across the country. So I was using an example. So if you go to medicare.gov and you type in that you want to look for a Medicare Advantage plan and you go to the plan and you put in your zip code and then you want to look for a Medicare Advantage plan and you go to the plan and you put in your zip code and then you want to compare plans and you go back you know you click through the fields it'll bring up all of the plans in your area in your zip code there might be 50 or 60.

And on the right side of those plans there's little boxes that they say they provide services in-home supportive care is home health aid services so if the plan says it that means that plan offers it as part of it so when they started this only 200 plans in the initial year of 2000 offered home health aid services across the country in 2022 1091 plans offered home health aid services across the country. In 2022, 1,091 plans offered home health aid services as part of their plan across the country. So we're seeing a massive increase. So a lot more people, and as we've all seen this as time goes on, is a lot more people are saying, oh, look, post-hospitalization giving them a home health aid is decreasing falls. It's decreasing issues. We're decreasing re-hospitalizations. Well, a week of a home health aid might be

cheaper than an ER visit. So we're seeing these plans are starting to really do some in-depth studies into these hours and these needs. And so they're offering more and more of these plans are saying, wait a minute, this is a benefit that's lessening re-hospitalizations. It's extending clients in the home environment. And so they're offering it in more plans across the country. Initially, when they first started, people were running away because the plans were offering ridiculously low rates.

And they were saying, well, that's the national Medicaid rate. Well, there isn't really a national medicaid rate so whoever came up with this rate or maybe it was a medicare rate whatever it was they were offering like 17 18 an hour for home health aid services that has gone away now and we're seeing plans like humana and minnesota offering 35 an hour in certain circumstances, in certain regions, in certain areas. So the plan itself, each localized plan in each individual state and each individual region can actually contract with a provider to whatever rate they want to provide it. So when you reach out to them, say, I want to be a contracted provider, they're going to give you a base rate, but that's a

negotiable rate that you have the ability to then, they can tell you, no, we're not going to negotiate with you, but you also have an opportunity to negotiate rates with them around what the community standard is and be more realistic for what's a living wage. Wow. A lot of good information. One, maybe a couple clarifications. So you go to medicare.gov find these plans, but then it's the MCOs, these organizations that establish the plans. So are the home care agencies developing a relationship with that MCO specifically? You know, like I have a relationship with Humana and they are my point of contact. Is that accurate? That's correct. But see, there's actually like an 800 number there within that plan that you can dial on and actually say, I want to be a contracted provider for health aid services. They're going to put you through to member service piece. They're going

to then set you up with contracting. It's going to be a process to get through to have this communication. But you can be contracted, same on Greg's home care of Southern Mississippi. I'm only going to contract with the plans that are in Southern Mississippi. I don't have to even have a national contract with Humana. I don't have to have a national contract with any of the other third party organizations that are out there. I only have to have a national contract with any of the other third-party organizations that are out there. I only have to contract with the ones that are close to me, which are in my area and

within my region. And if I look at those plans who provides in-home supportive services, that's the ones I want to target first. But what I will tell you is I've actually seen plans that say they don't offer that on their plan, but they have a client being discharged that the doctor wants them to have home health aid services. So they're reaching out to their in-network providers first and giving them home care because they can give it on a case-by-case basis, whether it's actually offered in the plan or not. Got it. Okay. Is this kind of an untapped segment? I feel like I personally don't hear of as many agencies going this Medicare Advantage route as I do the other sources. Is that accurate from your lens? Yeah. I think two years ago, everyone ran away from it like wildfire because they said, you're never going to get more than 120 hours a year and the rate's only $17 or $19 an hour. I can't pay my caregivers for that and I'm going

to lose services at 100 hours. But we're seeing the rates come up. We're seeing more of the plants offering the services. And I would use an example. I actually had a conversation with one of the states with a group or an organization that has multiple facilities inside of a state who's with one of the major networks. And they came back with 67% in 2022 of their Medicare Advantage clients converted to private pay. And that was on a number of about 120 clients annualized. So if 67% of 120 clients became private pay clients and moved over, I would take that gamble all day, every day from a home care standpoint to increase my private pay base, even if it is only 120 hours under the platform. Okay so is it also safe to say larger more sophisticated or robust agencies are probably better suited for these plans or is that

not necessarily the case? So here's the thing I actually think not and And here's why. Because I think if a lot of the large, sophisticated organizations are creating national contracts with the humanas of this world or the signas of this world or whomever it might be, they're creating them across the entire platform. But an individual agency has an opportunity to actually create a relationship with your local network and your local network with providers in your local network that has nothing to do with that bigger expansion. Does that make sense? So I don't have to contract with a national organization. I can actually just contract with my region, with Cigna in Central Pennsylvania or whomever it might be. Yeah, that's a good assessment, you know, that there's not a mold that an agency needs to fit to go down this path. Because like you're

saying, and like we talked through on the Medicaid side is that, you know, it's on a state by state, very localized basis for you to understand the plan and the hours and the prerequisites and make sure that that's a right fit. So to me, it's sounding like you need to go through this similar, very thorough process, understanding what's being offered and if it makes sense for you as a business. Correct. As far as getting licensed or accredited for Medicare Advare advantage what does that process look like and how does it maybe vary from medicaid or other kind of processes getting stood up you're actually going to be going through an individualized credentialing and a process with

whatever organization you're trying to be created they're going to ask you to fill out an application they're going to ask you for your license they're going to ask you for your license. They're going to ask you for your insurance coverages. They're going to ask you for the things that you would use to be credentialed. They're going to then probably do a background check on your company and OIG look and they're going to look at these to make sure that you're an appropriate provider to be within their network, they will then credential you into their network and set you up under contract. That's done on an individualized basis, office by office, area by area. Got it. So is it typical for an agency to work with one MCO,

knowing that there's like an application process per MCO? Or is it common to see agencies getting credentialed with multiple MCOs? I think it actually works best if you're with multiple. If you're gathering all this information and you're pushing it through, what difference does it make if you filled it all out for one or 10? However many are in your network, you're going to want to become a part of because that just gives you more referral sources that could be pushing clients back to you. And again, you have

the ability to negotiate whatever rate you find appropriate. The only thing they can do is tell you no. That's a good point. I guess I was envisioning the applications varying, but you're probably right. You know, it's pretty standard information and background checks and all of that. So if you're going to do it once, you might as well do it as many times as you need to, to increase your chances in the, in the regional market. It genuinely is. Let's talk about the administrative burden and the technology piece. Obviously with Medicaid, we referenced like EVV and what that looks like for Medicare Advantage. Are there specific

documentation requirements or processes that are different in this model? No, not none whatsoever. It's actually just like managing your private or your otherwise. You're going to be, other than the fact that you're going to, you know, they're going to send you an authorization with specific requirements for the client. You know, Mr. Smith needs bathed. He needs light housekeeping. He needs meal preparation. He needs these things accomplished. That's going to be part of your authorization. So your care plan is going to have to document the care you were providing. authorization tells you I need these specific tasks associated with ADLs accomplished and your caregiver documents that they sat and read a book to Mr. Smith for eight hours a day, okay, they can either deny and or come back and recoup that payment because you're not following the plan of care. But that can be with any paid service, whether it be Medicaid, or we didn't

really get into that too much, but we're talking about plans of care. But private insurances, managed care organizations on a large scale, have no issue whatsoever with coming back and recouping funds. If you're not following a plan of care, and you're not documenting the ADLs and associated care, they're paying for a specific service. And if you're not providing that service and you're not documenting it, they're not going to pay you for services. And I think what you're saying is pretty generic across the board. You need to have really well-documented care plans and care notes and care tasks. And I think that's, you know, kind of a standard across the board, but with each specific source that we're referring to here, they may have

specific requirements that you need to follow, but the idea being, you know, you need to be documenting very thoroughly and up to their standards. And I think with any third-party payer, you're going to find that to be a mandated requirement that you're documenting and creating consistent documentation to the services that they're requesting you provide. So just one more question for clarification. On the Medicaid side, you know, you referenced DVV. Is there any specific technological requirements for Medicare Advantage, or is that all through the MCO specifically? MCO specifically. With Medicare Advantage, are there surveys and audits, and what does the spectrum there look like?

Well, any third party payer can audit you on services provided, just like I was saying, if they come back and look at your care notes to make sure, but there are no like state surveys, there are no specific audits to timeframes. But again, at any given time, you'll find that part of your service contract within these organizations is they will say that they have the ability to audit services and or time services provided. And if the service that's provided doesn't match up to documentation of care, they can recoup their funds.

So less consistent hypothetically, but they have the power and the will to come and do it if something's awry. Correct. And usually it's done around, again, if you have a client complaint, if you have service issue complaints or something along that line, they'll come in and they'll pull a number of files to see, hey, look, send me Mr. Smith's notes and documentation. We want to make sure that everything's above board and that they're saying nothing was done. We want to see what you say was being done. And that's what they look at. That's usually what generates audits and concerns. But I think that some of the different managed care organizations are mandated to do a specific amount of files per year or whatever it might be, but they usually show you that or set that up aside. And it's part of what you're submitting to them for documentation anyway. So

they're doing an internal audit on paperwork. Okay. That makes sense. Well, to kind of round out Medicare Advantage, let's just recap, if you will, high level, the pros and cons of going this Medicare Advantage route. I think, I think if I, let's start with the cons. Typically, they're shorter hour authorizations. They're not giving a lot of time. You're seeing like 120 hours of annualized service authorization for care, and you're not seeing a lot more hours offered out to the client than that. So again, the thing that I would stress here, though, is clients that have Medicare and or Medicare Advantage doesn't mean they're Medicaid eligible clients. Their funding level has nothing to do with their insurance. 90 plus percent of our clients over the age of 65 have Medicare as their primary insurance. They can be incredibly wealthy and they still have Medicare as their primary insurance. So

it doesn't make any difference. So, but with that being said, it's usually shorter term, post-procedure, a couple of weeks, 120 hours, that's all the hours they're giving you. And then you have to be negotiating rates with them along the way to get the services. I think that would probably be the downside of providing care.

The upside of providing care is there's no mandate that they can only provide 120 hours. So it of providing care is there's no mandate that they can only provide 120 hours. So it really can be around doctor's orders, about levels of care, about requests by the agency to provide more services. And you have a huge upsell to these clients to allow them to become private pay clients, especially, you know, what we see is when a client gets a caregiver that consistently there, it does an job post procedure it's harder to say i don't want them back ever again and if they have the funding and they have the capability they're more inclined to keep that person that they've had providing those hours and say oh you're done with your 120 i'm

going to go to a different agency that's not typically what happens usually they utilize the same caregiver and the same agency to consistently provide their service moving forward. And the plans are expanding drastically every year. We've seen a 500% increase year over year each of the past three years moving forward. Good opportunities here. I'm glad that you recapped that because you actually clicked down on a few things that you didn't mention before. So really helpful. Thanks for covering all of this. I feel like an hour, we just went through so much, but I honestly feel like we were almost still like scratching the surface, but I hope that we've shared some nuggets on both the Medicaid and the Medicare Advantage

side. They are complex, but like you just broke down, you know, it's, it's less intimidating than I think sometimes people think. And there's very large opportunities here and large opportunities for this new revenue stream for your business. And so it's worth pursuing. It's worth looking into. It's worth doing your due diligence in your state research and figuring out if this is a good opportunity for your business. So thanks for covering all this. And our last couple of minutes, Greg paradigm helps significantly with what we've talked about today. And I want to give our last couple of minutes, Greg, paradigm helps significantly with what we've talked about today.

And I want to give you a couple of minutes to kind of get on your soapbox and share why agencies should consider working with paradigm if they are, say, intimidated or need assistance with some of this. So give us some words. Yeah, so I'm not going to cover, you know, we work with about 2,400 agencies,

give or take a little bit across the country right now. With Medicaid, I'm going to go into Medicaid specific because one of the huge challenges we're finding with Medicaid is to pull that information, to pull the information from your side to assist with shift verification, with coding correctly. And we're seeing a first pass run rate with zero rejections at about 99.86%. So we don't see rejections coming back from our Medicaid billing. The other thing is, is we're billing Medicaid on a weekly basis. And so with our managed Medicaid programs, we consistently see across the country, our revenue cycle is turnovers about a two week cycle. So we're seeing people getting their money back in two weeks. So rather than having 90 days or 180 or 120 to get paid, we're seeing people

consistently being paid in two weeks from their revenue cycle. On the managed care platform, we typically are seeing them on the Medicare Advantage, a weekly revenue cycle. So we can set up the billing cycle for them. We can actually assist with all the credentialing and getting into network and creating all the credentialing from start to finish and then managing the entire revenue cycle on Medicaid. But on the Medicare Advantage, we can do the same thing, helping them with the credentialing from start to finish and then managing the entire revenue cycle on Medicaid. But on the Medicare Advantage, we can do the same thing, helping them with the credentialing, with network, understanding the credentialing for network, getting through the processes,

and then following up and doing their billing all the way through the cycles. So you help with the full suite. I don't love the term end-to-end, but really you help with credentialing all the way through, you know, automating, automating that billing and the revenue cycle management. So there's a lot that you all help providers do. So if you're interested, again, paradigmseniors.com is where you can learn more about Paradigm. And if you want to contact Greg, I highly recommend connecting with him on LinkedIn or get acquainted with him. He's got a really strong team alongside of him that can answer all of your questions. So, Greg, thank you again for joining me. I know you're hot off of vacation, but take a deep breath and know that

you made it through and we really appreciate all of the insights you've shared. Thank you so much for your time. That's a wrap. This podcast was made by the team at CareSwitch, the first AI-powered management software for home care agencies. If you want to automate away the menial of your day-to-day with AI so that you and your team can focus on giving great care, check us out at careswitch.com.