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By Sarah C. Threnhauser

I spent the day in a session, Marketing To Managed Care: Issues In Providing Mental Health Services For Commercial Insurance & Managed Care Plans, led by my colleague, OPEN MINDS Senior Associate Steve Ramsland, Ed.D. His opening question – are you focused solely on yesteryear’s payers and contracts? Or are you looking ahead to the payers and contracts you will need in a managed care world?

While managed care has been around for years, we are seeing new consumers in managed care plans and new managed care markets. For the first time, many states are mandating that individuals with a wide range of disabilities are enrolled in managed care plans. And foster children. And the dual eligible population. Managed care in Medicare is on the rise as well. In case you’ve missed it, we’ve covered this shifting role of managed care over the past year:

  1. Illinois Medicaid Mandatory Auto-Enrollment Launches July 1, 2014
  2. Indiana Seeks Risk-Based Medicaid Managed Care Services For Disabled Beneficiaries
  3. New York To Open Applications For IDD Managed Care Entities
  4. Texas Medicaid To Establish Mandatory Managed Care Program For All Youth With Disabilities
  5. New Jersey Medicaid Launches Managed Long-Term Services & Supports Program
  6. West Virginia Medicaid Launches Health Homes For Behavioral Health
  7. Kansas Medicaid Launches SMI Health Homes, Postpones Launch Of Chronic Conditions Health Homes
  8. New York Medicaid Releases Draft Application For Children’s Health Homes

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To be prepare for this new wave of managed care, proactive positioning and proactive conversations with the managed care companies that are dominant in your area is a strategic must, according to Steve. In his workshop, he laid out a “Managed Care Preparation Checklist” to start the conversation with your team.

Administrative Checklist

  1. What systems are in place to secure and execute contracts with health plans – and communicate those provisions to key staff?
  2. Are your internal administrative systems in place to assist and support the professional staff working with a health plan (intake, benefit verification, utilization management and billing systems)?
  3. What systems are in place to track health plan authorizations, review managed care clinical criteria, and product appropriate service documentation?
  4. How much of your health plan revenue is being written off because there are no clinical or administrative systems in place to track utilization of authorized services?

Financial Checklist

  1. Who are the largest health plans and payers in your market? Do you have a contract/relationship with those organizations?
  2. What are your unit costs and will contracting with a specific health plans cover those costs?
  3. What is your policy regarding co-payments and deductibles? Are they being collected? What role does repayment play in the “recovery process”?
  4. How much revenue is your organization writing off because of no contract or being “out of network”?

For more on these issues, check out these resources in our Industry Library:

  1. Preparing For Value-Based Contracting: The OPEN MINDS Toolkit
  2. Narrow Networks Happening By Design & By Default
  3. Making Health Homes Work – Advice From The Field
  4. ‘Pay For Value’ Making Its Way To Practice
  5. Health Care From The Bankers’ Perspective

And, if you couldn’t join us in Gettysburg for the 2014 OPEN MINDS Executive Leadership Retreat, be sure to check out our coverage on Twitter @openmindscircle #ELR14, and look for photos of the retreat on our Facebook page at https://www.facebook.com/openmindscircle.

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