Latest / Home Health Revealed (+Palliative and Hospice) / 131: Your Managed Care Contract Called: It Wants a Raise

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131: Your Managed Care Contract Called: It Wants a Raise · Home Health Revealed (+Palliative and Hospice)

• 0:02
  Speaker A: You're listening to Home Health Revealed, where the business of home health comes to life. Hosted by Hannah Vail, each episode brings real conversations with the leaders, innovators and experts shaping the future of the industry. From reimbursement and technology to leadership and growth, this is Home Health Revealed.
• 0:17
  Speaker B: How's it going? Good.
• 0:19
  Speaker A: Busy, busy, busy, busy.
• 0:20
  Speaker B: I believe it. It is like every day anymore. I feel like I'm having conversations. In fact, I just got off one this morning. People asking about managed care contracting, about what to do. I just feel like we're at a point where the services you offer, everybody needs somebody they can trust to know if they're doing the right things, if they're getting the pieces of the contract in place. So I'm really glad we're having this conversation. Yeah, let's go for the intro. This is Joe Russell. He is the founder and CEO of Yield Health, which is a provider side firm that helps home health, hospice and post acute agencies get paid what they've earned from managed care. I think that's so Joe has actually spent 14 years in home health policy and managed care. Before founding Yield Health, he led contracting for home health and community based providers at Strategic Healthcare and Yield Health now manages Southwest Care Partners Network in Oklahoma. So very cool. Tell us a little bit more and then we'll dive into some questions I have for you.
• 1:22
  Speaker A: Thanks, Anna. I appreciate the opportunity to be here. Yeah. I didn't come to found Yield Health from a specific. Like it wasn't like I woke up one morning and said, aha. This is the thing it was really more of in my role at the Ohio Council for Home Care at Hospice, playing that advocacy role. People coming to me over and over and over again saying we've got problems with these managed care companies. I wasn't able to move the needle in our advocacy and lobby efforts with the state in the health plans. While they gave us a lot of lip service, it was just that lip service. And so I, I recognize that there was, you know, healthcare is a formally regulated marketplace now and there needs to be new mechanisms in place for providers to be able to convene in a legal way to be able to push back on some of the market dynamics. And what I really realized is that led to the, to me founding Yield Health was, you know, payers are bringing deep data to every conversation and every negotiation they're having with providers. But most providers are just bringing their last contract to the conversation. You're never going to win when that happens. And so I also recognize that the provider Most providers don't have the capacity to do this on their own. And so fast forward for a lot of, a lot of long nights, a lot of hard work, and here we are doing the great work of managed care for, for post acute providers across the country.
• 2:47
  Speaker B: For agencies who are going it alone. I think there's always this question about the gray areas. And then what do I not know? What are other people getting that I don't know if I'm getting or not? Is this a good contract? I don't even know. So having somebody like you who's had eyes on regions, on national kinds of statistics and averages to say, yes, this is good. Here's another lever you could pull though, within this contract because it's not always rates. It is, and we want better rates. But there are other things within a contract that really be beneficial and make or break a good timeline and a good relationship for these agencies. You're also a dog person. Not to get us off track, but your dog just had a birthday.
• 3:27
  Speaker A: He did three years old. Elvis Allen is his name. He's an old English bulldog. I know I had a boxer previously and I thought the boxers had a very human like personality. But these bulldogs, if you've ever been around one, they're, they're, they're smarter than you think. They're very, very stubborn. He wasn't really sure why he was wearing a hat, but he was excited to have all these extra snacks. So I think his birthday was more for me than for him. But it was, it was great. I enjoyed it.
• 3:54
  Speaker B: I love it. And I love seeing all the pictures of Elvis. Love that name. My daughter is turning 10. My youngest daughter is turning 10 next month and she's been dying for a dog. We have a family dog. We surprised her on Monday.
• 4:08
  Speaker A: That's awesome.
• 4:09
  Speaker B: I thought by 3am I was going to be sorry, but this little puppy has been the cutest little thing here. I'm going to show you a face. This ought to make our podcast be really, really. Everybody loves to see puppies, right?
• 4:21
  Speaker A: Oh, my God. Goodness.
• 4:22
  Speaker B: Her, she's, she's adorable.
• 4:26
  Speaker A: She's tiny.
• 4:27
  Speaker B: She is. She's a cat. She is. And I mean, it's been a mom win. So Susie J. Is like, mom, I love her so much. I love her so much I could cry. I love her so much. She was like, take good care of her while I'm at school today. But not too good. So she loves you more than she loves me. I was like, that's.
• 4:45
  Speaker A: No, I won't bring mine Mine is on his third nap of the day, so if I wake him up, he's going to bother me the rest of this time, so. Got it. Yeah. Follow me on Instagram if you want
• 4:55
  Speaker B: to see all things Elvis, Elvis and Elvis sighting. Yeah, so, so fun. Anyways, back to managed care. One of the things that has come up more and more is denials and authorizations that are related to authorizations. Can you talk about where that really starts?
• 5:14
  Speaker A: Yeah, I think a lot of providers focus in on the denials and authorizations when. When they kind of see some revenue issues or some problems. Because it's very clear, right. I mean, there's evidence that. That these things are happening, and at least we hope and to some extent they're solvable. But where it really starts is with the contract. Most agencies are underpaid by contract, not by accident. And so, yeah, you can get the denial. It's loud, it has a code in queue, but an underpayment arrives looking exactly like a payment. Right. So I see this a lot with our clients. When we bring them in and start analyzing their data, we find out that, oh, my gosh, you actually negotiated a pretty decent contract eight years ago that had step increases in it, but that was never communicated to the Rev Cycle team or to the team managing those systems. And so the payments were never updated. And so you're literally leaving money on the table. And the billing system's part of this. And I know we've talked about this a lot. The billing system's part of this is a big deal. You know, those systems check claims against what the payer paid, but not against what the contract says that they should be owed. So it's really important to be reviewing those things on a regular basis and making sure that those rates that are in those systems are accurate. You know, there's a lot of patterns that you can find when reading these. These contract portfolios. You know, you've got your rate schedules that point to, like, a fee schedule, which, you know is never kept anywhere. Nobody knows what that is. It's just in the system, you've got a percentage of Medicare. People love that because it's like, oh, I'm getting the Medicare rate. But sometimes if there's no year named, it can quietly freeze the rate. And so, like, if you negotiated 100% of the Medicare rate today, what is that going to be in five years? If. If it's frozen? Right. I talked about the escalators. The contracts with auto renewal are the ones that kill the most because those terms are set when your agency not only was half the size it is today, but you had half as many Medicare Advantage or Medicaid managed care patients as you did. So you have this, you literally. That's probably the biggest issue I see is most people that come to me have this portfolio that was created but was never managed. And so you have a, it's no longer keeping up with your agency. So with Medicare Advantage now covering more than half of Medicare for most agencies, if they're not actively managing their portfolio, then it's going to be problematic. But you know, freestanding home health agencies, according to MedPAC, have a 21% around their fee for service margin. And when you would you distill it down to all payers, which includes Medicare, Medicaid, Medicare advantage, it's about 5%. So there's a big delta, there's a big gap. But I would say the biggest issue, the biggest problem isn't, isn't just denials and authorizations, it's also being underpaid.
• 8:17
  Speaker B: Yeah. And I think one of the questions that comes up sometimes when I'm talking to especially newer agencies, they get their ptan, they get their Medicare number, they can bill, they do. I go ahead and try and pursue contracts with these managed care payers. When is the best time to do that in your opinion?
• 8:37
  Speaker A: That's a really great question. There's, there's no specific right answer to that I can't think because there's, there's a lot of different factors that go into it. But here's the way I look at it, especially on Medicare, you're going, you're going to get paid 100% of the Medicare rate for being out of network. The caveat to that is you have to get authorization to get paid. Right. And then there's also a co payment component to that that you can't just throw away and write off. And you can eventually write it off, but you have to try to collect on that. So what I usually recommend is the first thing is if you're a new agency is build your community relationships, find out where your covered lives are. That's one of the primary services that we offer is a market analysis. Where are your covered lives? Like if you're in a rural area or if you're in an urban area, you might be a big populated state, but there might be one or two plans that rule the roost in your market. So obviously those are more important. But develop those community relationships to see the referral patterns and then begin by doing out, out of network Admissions if you do, if you're successful with those you can make, you can do really well. Eventually that health plan is going to come to you, come knocking on your door and saying, hey, we want you to come and network. You're doing too much out of network volume. That's when you've just created a significant amount of leverage for yourself. Even if you are a new agency, the problem with being new and going to the plans with nothing is you don't have any leverage at all. You are literally going to be offered the floor rate. You're going to have to accept the floor rate because you have no negotiating leverage. And right now in Medicare Advantage, the depending on what state you're in, you know that skilled nursing rate is around Medicaid number. So yeah, you got to do what you got to do. I think it does help your company to have some contracts. So you don't want to just say it's not important. But I like the approach of trying to do some business out of network, garnering the attention of the health plans and then it puts you in a better situation. Of course, even if you go to the health plans and try to get in network, a lot of times they'll say it's closed for right now and so you might not be able to get it anyway. So.
• 10:48
  Speaker B: Yeah. And then what data can they collect really to say, okay, we do this well and this seems to work well for this payer. I know that takes time and the last thing you want to do is spend time gathering data at the beginning. You just want to get a patient in the door sometimes. But if they're really thinking about it and being strategic, what is the data they want to start collecting?
• 11:11
  Speaker A: Yeah, so there's a lot of different factors that a health plan takes into consideration of, of, you know, if they're going to offer you a contract, one, and then two, what the rate set is going to be for that. And you want to look at it not just in, in your line of sight, but just the global purview of what the health plans are looking for. Generally speaking, there if you're, they're going to be looking for additions to their network that they don't already have. And so that's going to be things like strong quality metrics, like really strong quality metrics where you can show your total cost of care is less than your peers, your re hospitalization rate is less than your peers, or you have some sort of special program. Like for example here in the state of Ohio, you know, infant mortality is a really big deal. Ohio ranks on the lower end in terms of the states. So if you have for example, some sort of community based program where you know it's a pediatric program or you're, you're working with maybe you know, the different local departments of developmental disabilities on early intervention programs or some of these things that are really unique, that's, those are sell points to the health plans are like, okay, this person's different, this group is different. I kind of want them in my door. You know, they seem to be operating well and those sorts of things. So from a. Data from a. What do I bring to the table? Well, you're gonna, first of all, if you're already in network, you, you, you need to know what your realized rate is currently. And that is really difficult for most providers to get. In fact, most providers don't even know what I'm talking about. Probably, but maybe I shouldn't be so coy on that. But know your numbers first and foremost. So know what your cost of care is to provide that nursing visit, not what you can get paid off of it. What does it cost you to send a nurse out? And then what are your global quality metrics, your star rating, your total cost of care, your rehospitalization rate? Those are kind of the big three that you're going to really want to know. But at the end of the day when you're going into these negotiations, you don't want to be focused on entirely on your contracted rate. You want to be thinking about your realized rate. This is the floor at which you break even. So your realized rate is the contracted rate, but less the, the denial write offs, the, the underpayments, the timely filing and unbelievable losses. All of that stuff that you guys specialize in kind of addressing, that's your realized rate. So for, for like an example, if you're, we're talking ma skilled nursing visit, if it pays $120 against a. And you're all in cost to provide that visit is $97. You have, it looks like you have a margin of about, you know, like $23, right. Taking out a 9% denial write off and a 4% underpayment leakage. Now all of a sudden that rate is about $105 and your total margin is $8. That's a vastly different gap. So the real lesson here is that $120 a visit for skilled nursing isn't necessarily a bad rate. What's bad is that nobody can tell you that it was a good rate because the Calculation was never run. So when you go into these negotiations, don't just know what you're being paid, know what that contract offer is going to be against, what your costs are all in on your operation. That's how you're going to make margins and that's how you're going to win in the business of managed care.
• 14:53
  Speaker B: Yeah. And bringing that to their attention, that's where you have real power in the conversation. Now if so given all of that, and that's where you're getting down to those single digit margin numbers. Say an owner goes home after this conversation, they pull that contract out of their drawer. What is the first thing they should read?
• 15:12
  Speaker A: They will read the title, that's for sure. The, the first thing that they, that, that you need to understand with these contracts, the first when you pull it out of the drawer is you, you need to know the age of it. When was it signed and more importantly, when does it expire?
• 15:31
  Speaker B: Yeah.
• 15:32
  Speaker A: Because that is your window of opportunity. And if, if, if you, if you do this tomorrow or even do it today, pull out all your managed care contracts. If you don't have any, or I'm sorry, if you have contracts but you don't have copies of them, the first thing you need to do is reach out to the health plan to get a copy of it. But look at the age, how old is it and when does it expire? The biggest problem of all the problems that exist in managed care again is not actively managing the portfolio, which means that you are not, you should be going back to the health plan when your contract is six months out from expiring. So that way you have a negotiated, new negotiated rate in place when that thing expires so that you can move on with the new rates. So look at, look at the date, look at the, the, the renewal time. If your contract is outside of its original renewal day, you can go back at any time. You don't have to wait again. So if it's generally a three year, three year contract, if you're in year five, Right. But you're in the middle of the year, you can go back to them and request a renegotiation right away. You don't have to wait again. But those are the two things I look at first. But it's important to view contracts really as a set of five documents, not just one. So you've got your base agreement that has your normal terms in it. You also have the provider manual which incorporate is incorporated a lot by reference. And a lot of providers don't know where to find those. They're not looking at them. Obviously the rate exhibits and the attachments and then the product participation schedule. One of the things I've been seeing lately is super sneaky, but that's the health plans are sneaky at times is they don't come and call out the, the new D. SNP products. They include them by reference. So they'll say, they'll say the Medicare Advantage product and then the Medicaid managed care product but they never say anything about the dual product. And, and so that, that's a line of sight that a lot of people are missing. So what products are in it? Right. Are we talking just Medicare Advantage or are we talking everything Right. I always try to negotiate as long as the agency wants is to get all of the products in there right. There's no reason get your Medicare Advantage, your, your duals, your Medicaid and your commercial. There's nothing that requires you to serve those patients right. But having them in network gives you peace of mind. In one contract, not five different contracts. It really helps. But obviously there's a lot of things I look at besides the date. That's the first thing I look at. But I'll also look at the rate basis. It's obviously look at if it's fee for service versus episodic but as I mentioned earlier, if it's episodic, if it's a percentage of Medicare, what what's that tied to? Is it just this year or five years ago or is that you're going to get increases when everybody gets increases or decreases on the Medicare side, your escalators. One of the biggest mistakes providers make when they sign agreements is they sign agreements that have our multi year agreements, they're evergreen but there's no escalators in them. That's an easy ask. Typically, especially if you got to a place with a plan that's not going to give you more money and you're not happy with the rate is saying fine, give me 3 or 4% increases per year over the life of this. That helps me out. And then a lot of times they'll do it. Obviously the term in the notice window does it auto renew and how long do you have to give some. Some of These contracts say 120 days, which is four months. That's a big, that's a big time period. Right. And it's really hard to make a decision about what you're going to do four months away from when it's actually due. Timely filing. I know that's Something you love that yes, under 90 days is a risk, a huge risk. So you want to be asking for at least 90, if not 180 days with that. At least. That's how we approach.
• 19:24
  Speaker B: Ask for more, ask for the most you can get. They can say no.
• 19:27
  Speaker A: Right? And that's the key is like, oh, gosh, I'm so glad you said that because I deal with providers all the time that have this approach with managed care where they are literally afraid of them because if they lose that contract or referral pipeline, they think that their business is going to go out of business. And maybe for some that haven't diversified, that could be the case. But unless you break the law or there's something egregious that's been happening like fraud, waste and abuse or something clinical, these health plans aren't going to do anything. They're very numbers driven. They don't even care that you have feelings, quite frankly. So you can ask for, you could ask for five years, right? And the worst they're going to laugh at you, but at least worse they're going to say is no, they're not going to say, you know what, we've decided we're not going to give you a new contract because you asked for something ridiculous. Right on the, right on the, on the timing of the, and the recoupment look, recoupment look backs. We always look for a reciprocity. If they have, you know, 12 months to, to look back, it's not unreasonable to ask for 12 months for timely. Right. I mean that's again, you can ask for whatever you want. Some, some of them will do it. And then the other thing that you want to look at is what are the manual changes in unilateral amendments? Because they'll slip things in that end up being really bad for you and you have like 60 or 90 days to contest it. And if you don't, then it just goes into the contract. So know what those clauses look like. Yeah, but I, I think the dates are explicitly important and I, what I would charge everyone with is put all your contracts, termination notices on your calendars with at least 120 days, if not six months ahead of the renewal period to get out. Way ahead of it. So that way, you know, hey, this contract's up in 8:1. No, this contract is up at April 1st of 2027. Okay. We'll get it on your calendar six months out that you need to start engaging that plan to renegotiate.
• 21:28
  Speaker B: Exactly. Now with recoupments, what is a Good average time period for recruitments, is it 12 months? Are you seeing less than that?
• 21:35
  Speaker A: I always look for reciprocity in
• 21:41
  Speaker B: just whatever they're asking for. We want the same.
• 21:43
  Speaker A: Yes, okay. Yes. So it to me, I mean obviously you don't want it to be too short or too long. Right. For. Well, you don't want it to be too long for recoupments. But honestly 12 months is sort of like where we're kind of draw the line. We try to draw the line anyway. But yeah, that's, but we look for reciprocity and we look for reciprocity and then we look for 12 months or higher.
• 22:06
  Speaker B: What about days to payment? Like is. Are they you seeing anything with that? With how quickly they have to pay you?
• 22:15
  Speaker A: The stuff that I see is, is usually, it's usually standardized language. It's not like specifically negotiated in contracts and or it's tied to a state law. Like some states have timely filing requirements and that also include timely payment. They don't want to, I'll tell you this, the health plans don't want to pin themselves down to any timeframes if they could. And so but generally speaking it's very generic language where it's hey, they have X amount of, of time to actually pay you. And but I don't know if you guys see this, but I often see games being played where an easy way to. If they don't think they can pay you in a certain time frame, they can always just deny the claim and pun it and try to get you to go back and collect it.
• 23:04
  Speaker B: But yeah, we're seeing even they'll kind of restart the clock or like you said, send a denial and, and then I have to think this is my pessimistic way of thinking at the moment about it. They're counting on the fact that agencies don't have the additional manpower to make the phone calls follow up do. There's a lot of work that is having to be done and we're seeing more and more across our teams. Time spent on the phone, time having to escalate. Things that really should be paid are very reasonable.
• 23:38
  Speaker A: Yeah, I think it's, don't get me started on this but I think it's a crime. I mean they're asking you for a pre authorization for a service that requires a physician referral and then they don't pay you.
• 23:51
  Speaker B: Yeah.
• 23:52
  Speaker A: And most of the time they're not paying you. It's administrative thing. Not, not a question over should this patient have received the care? And a lot of Times they don't even the health plans because they don't know, frankly, they're not even making the claim that you did a bad job providing that care. They're simply running as many traps as they can to, to try to not pay out because they want to keep their balance sheets. And I don't think that's, I try to tell providers that don't take that personal. This is how they conduct business. If providers want this to change, what's going to have to happen is providers are going to have to come together and work on that collectively. We do a really good job of, of that, bringing providers together through our clinically integrated networks. And it's amazing, Hannah, the problem, the administrative problems that we see in these networks go almost to zero after these providers convene because they, the providers know they are, the payers know they can't get away with the stuff that they pull on individual providers because they have a network that backs them up. Plus they're dealing with, you know, 25, 30, 50 different providers. It's just not worth the squeeze. Right. But when you're alone out there, especially if you're small, especially if they've got evidence that you don't know what you're doing or struggle with revenue cycle, yeah, they'll run you through that woodshed for sure.
• 25:15
  Speaker B: No, there's definitely power in numbers. For people who are not a part of a clinically integrated network or some kind of collective power, it's definitely worth it. Not just from the information and the advocacy, but also just the, the camaraderie. And I'm 110% behind you on this. Agencies are going to have to come together to fight for what we need. And when we're fighting for these payments, these agencies have already fronted the money to pay their clinicians to pay their office staff. We're already on a dso. That's insane compared to other disciplines, other types of business that are out there. I feel like we're running this backwards from the start and we're doing the hard work and then we're having to go prove that we did the hard work just to get paid sometimes even at a fraction of what it cost us.
• 26:05
  Speaker A: So it's, it is I optimistic and I believe that you were. We're in a place now where I think it's going. More eyes are on this, these issues and it's going to get better. But I'm not naive to think it could get worse before it does get better. I mean, we've seen a lot of Movement on the prior authorization front, which has been good. I think there's been some implementation issues but like for example starting in March of this year the plans now have to publicly post their prior authorization metrics. So now there should be no question of denial of a pre based on a pre auth because your organization should have that information. You should be able to clear that bar every single time. But yeah, it's going to take providers coming together. I would like to see more advocacy in the industry in Washington on these issues. Now is a really great time because there's so much scrutiny on the health plans but and recognizing that they have health plans have an important role to play, right?
• 27:10
  Speaker B: Yeah.
• 27:10
  Speaker A: The healthcare spending in this country is out of control. Part of that is over utilization of or unnecessary utilization of healthcare services. I go get an MRI or an X ray and then they refer me to another place and I get another X ray. Those types of or you have an acute stay at a hospital and they say okay, you're going to be referred to a home health agency, they're going to reach out to you and then you don't ever hear from anyone. Things like that that are really chewing up costs. And the health plans play an important role in helping our health care system utilize, not utilize unnecessary resources but the way they're doing it is through utilization management of provider services, not necessarily incentivizing providers to do certain things, which is where my head always lives is like don't tell me what to do, give me the incentive and I'll go do it. The the market is changing and I don't know that a lot of providers recognize the, the amount that is actually changing. You've got all this stuff that CMS has been doing over the last three years with the age friendly initiative, the continual expansion of the ACO program into, into leads and obviously still, still leveraging teams. But there's also new things coming down the pike. They there was a pilot a number of years ago for bundled payments for knee replacement or joint replacements. It was hugely successful. CMS is now implementing that which means that the hospital now is going to be responsible through a bundled payment for what happens to that patient 90 days after discharge. Well that's a home health world, right. And so and if you're a home health agency on a joint replacement that can't do its work in two to three visits for maximum, you're going to get pushed out based on cost and data. So how do you as a provider get position yourself to stop thinking about, you know, volume on a fee for service contract to now start thinking about value on an episodic contract with upside of, of shared savings opportunities because that's where everything's moving. So it's not to say that there weren't, won't be some intermittent, traditional intermittent care home health agencies around the country, but for the vast majority of providers, in order to survive, you're going to have to have a diverse portfolio of some fee for service, you know, some traditional Medicare, some value based stuff, you know, and that's very, very challenging to manage on your own. And again, it's one of the reasons why we're going pretty hard in on the clinically integrated network stuff because the network then provides that mechanism for providers to perform in that environment, up to and including providing the analytics that are needed to, to monitor and provide clinical care in real time and intervene in real time. Those are, that's where health care is moving. And I don't think a lot of providers, at least a lot of providers that I've spoken with kind of see that coming and you know, they're trying to manage their portfolio that's outdated. They just want 10 more dollars on their fee for service and they're not positioned well for what's about to happen to them. So it's challenging. No, it's challenging for sure. But I think for the agencies that can figure this all out, there's going to be a lot of meat on the bones for sure. You're not going to be fighting every single visit to get paid. You're, you're going to have, you're going to say, okay, how do we, how do we maximize delivery care? Because we know that this is where it's going to lead us in the long run.
• 30:46
  Speaker B: Yeah, no, I like how you're talking about sharing that from the provider and the payer because I think it's easy for us, it's easy for me sometimes to criminalize these payers and see them in a very bad light. But I think your points are very valid and we have to work together. We have to learn how to share the risk and the reward of good care, of value based care. I think a lot of agencies do feel that they don't have any leverage right now with these national Medicare Advantage plans. So where does that leverage actually come from? And maybe this is what you were referring to with the clinically integrated networks, but maybe there's more to it.
• 31:28
  Speaker A: Yeah. So where you're able to push the health plan is all about leverage and that might not make sense to a healthcare Provider, you know, like, well, I'm providing care. These people, you know, why won't they give me more money? I can tell you where it's not. It's not in the response that we deserve more just because again, it's worth noting that the health plans are coming to the table in the negotiations with you with a ton of data on you. And so going to them and saying, well, we deserve more just because you're not doing the best job you could at managing your costs or your people isn't their problem. Right? They're going off actuaries and things like that. And that's going to be harsh for a lot of people to hear, but it is the reality. At the end of the day, your rate is a cost line item in a business whose revenue the plan locked in a year earlier. So the argument that works really is I save you more than I cost you. That's the key. It's all about to create leverage regardless of how many providers you have together at the table. To say one provider, it's not because I deserve more, it's not because I'm important to you, it's I save you more than I cost you. And you want to be able to provide that information to the health plan to show them, hey, if not for my organization and taking this level of referrals from your health plan, this is what it would have cost you to pay an out of network provider. You don't want to talk about what you deserve or you don't even want to even unless you can prove it with data you don't even want to tell that. You don't even say to them that you're a good agency that everyone loves. If you're a good agency that everyone loves, your quality metrics will show it and your HCAPs will show it. You don't have to tell them that, they will know that. So you kind of want to, we want to retire that myth that they're going to give you more money. In fact, I just finished finished a negotiation with one of my clients who is a singular organization. They have a decent sized footprint in an urban area. They went to a large health plan and the health plan flat out told them we're not giving you any more money. The reason why was because they don't have volume with them, meaning they've been in network for several years. But they've, because the rates were so low, they didn't take admit a lot of those patients and so they're not giving them a raise. So it stinks because you're going to have to start taking those patients. And so one of the things that can create a lot of leverage is get comfortable with the word no. You're. One of the weakest strategies I see from a provider is I have to be in network with everyone in my market because I want to be able to take a referral from a, from a community partner if they have it. It's like, well, okay, but you're never ever going to get more than $90 of skilled visit because you don't have enough volume. It's better to get a single use case contract or single case contract and, or get authorization out of network than to be in network with the payer that you're not taking volume on. So that's a really good point. Yeah, it's, it's what I call out of network math. And you should do this with every health plan in your market that you do business with. Obviously there are always going to be a group of providers that you rely on. Right. And you don't want to mess too much with being on a network or whatever because it could fundamentally hurt your organization, at least in the near term. But you don't have to do business with everybody. In fact, you shouldn't. And if again, going back to our first question of how can you get their attention if you, if you don't have it? Well, start taking people out of network and start. Of course, it has to be a PPO plan in order to do that, which means that you have probably 40%, maybe 50% of all those referrals that you can even take. You're going to be making more money serving less people by doing that than you are if you're going to do the volume game on a bad contract. But quality is currency, whether we like it or not. They love the health plans, love star ratings.
• 35:28
  Speaker B: Quality is currency. I like that.
• 35:30
  Speaker A: Yes, absolutely. So what is your star rating? I know that a lot of providers don't like it because it doesn't tell a good story, but it's also one of the easiest metrics to move quickly. I've seen providers come into some of our networks that are two star on paper and within two quarters they're, they're three and a half, four stars. And it's just because of the way they were managing their oasis and managing their staff internally had nothing to do with their actual quality of care or anything else. And so Starrings again, we see that a ton. Total cost of care, readmissions, hospital readmissions. You know, if you're able to bring the avoided readmissions and SNF day math kind of like together. Meaning like how much is this person chewing up in the, in the ecosystem not just with you? Those can be super helpful. They plans will also pay for operations. One of the ones that's probably the most important right now is how long is it taking you to start to do a start of care for a referral. Medicare, you know, says it should be 48 hours. Some of these health plans are taking way longer than that. But I can tell you the ones that can do it in 24 hours are the ones in the upper echelon that in and of itself can get can move that payer to want to pay you more money because they know that start of care is going to happen really quickly.
• 36:48
  Speaker B: Exactly. And that's also going to reduce re hospitalizations. That alone timeliness of initiation of care impacts so many other metrics. If you're communicating they know what to expect. It's going to impact your rehospitalization rate because they're less likely to miss medications and just sit with those question marks about what's going to happen.
• 37:08
  Speaker A: Absolutely. Absolutely. Another, another piece is timing. Medicare Advantage bids are due the first Monday in June for the following plan year. So plans build networks in Q1 and Q2 and everything calls in quarter four which is too late. So if you're calling in quarter four, you know, again you can kind of manipulate that timeline because you can't go to negotiate before your contract window is is up, but you can after. So if your contract window is up in October nove, it's worth waiting till January to circle back. That's sort of the sweet spot. Oh, here's a good strategy that I've used and has been really highly effective. It kind of all starts with creating a payer strategy. So not just willy nilly going to plans and getting know which ones are the most important ones and and then which ones are the smaller regional plans versus the big national plans. The regional plans pay better because they're trying to get network adequacy, they're trying to attract good providers and they want to grow their, they want to grow their, the size of their plan. For example, if you got a small regional plan and you can negotiate 100% of the Medicare rate and but they don't have as many referrals. That's okay. Admit as many of those referrals as you possibly can. Right. And then take those, take those, those patients you would normally admit off of the big Plans just reduce those numbers. So start moving away from the consolidation of the big health plans in your portfolio and looking for other opportunities like you. You could go to health systems and contract directly with them. You can go and I mean, obviously there's ACO opportunities, although I very much weary of them. For most home health agencies, don't sign those unless you know that like you have a clear plan. Just getting your foot in the door is not a good reason to be in an aco. Really look at where, where can I maximize my reimbursement through, through managed care? Not just where my covered lives are or who the big health plans are. Because a lot of times you can negotiate some really great deals with those smaller plans. But smaller agencies rarely went on rates alone. They went on terms, they went on timing, and they went on proof. And those are the things you should be thinking about as an agency.
• 39:27
  Speaker B: And that's really what you're building at Yield Health. So I want you to talk a little bit about that, about what you're building there, and then let listeners know if they want to talk more with you or they want to discuss Yield Health's opportunity. Where can they find you? What do you do? Give me the, give me the lowdown, Joe.
• 39:46
  Speaker A: Well, I live in a bunker three light years below sea level, so it's hard to get at me. No, I'm just kidding. So at Yield Health, we're a provider side revenue intelligence firm. Really? Managed care revenue intelligence firm. You know, we read the agency's contracts against the market and we use data to build a plan for our clients on not only how they should be generating winning portfolio, but also tools on the negotiation part of it. We're bringing data, information and expertise to that, to the table that, you know, I'd say 90% or more of agencies don't have internally. You mentioned that this has all come together because of my years of experience. Half of my career was in, was a healthcare lobbyist and then I ran the Ohio association for a time and, and then I got into being a full time managed care consultant and building these clinically integrated networks. And so I've learned, I had a lot of learning on the job.
• 40:46
  Speaker B: That's the best kind of learning on the job, doing what you got to do, flying the plane while it's in the air.
• 40:51
  Speaker A: Absolutely. There's a lot, a lot of lessons that come with pain. Right. And so what I've done is I've taken all this experience and I've brought together a really great team. We've created some really special data modeling that, you know, what we're, what we do for our clients is. The first thing is we analyze the existing contracts against your revenue cycle operation to identify, okay, where are the opportunities to close revenue cycle leaks attached to your managed care portfolio? We do that market profile that I mentioned previously. Where are the covered lives, where the health plans, who are your competitors? We do a quality profile that tells you exactly where you're winning and losing in your clinical quality profile. And actually, one of the biggest things that's come out of this work that I've been doing is actually telling people where, where they're going to land in the next round of VBP adjustments. That seems to be like, nobody knows that and which is crazy. That's not even an area that I work on. I had a client that I was able to identify. Guys, in the next round of adjustments, you're going to lose 4.8%. So whatever I get you in these contracts is going to be ripped away on the traditional Medicare side because of your quality. And so just finding an understanding what the data is and then putting that all together into a payer strategy that, you know, everybody wants the loop a rate or everyone wants, you know, the Medicare rate, but no one can ever tell me why, because for most agencies, their, their numbers, their data and the data from the market does not support that. Right. And so what happens is you leave a negotiation wanting $175 a visit, ending up with 125, and you're all, you're all upset. But what you don't know is that 125 is performing 5% better than everyone else in your market. So that's a good contract. Right? So those are the things that we're doing. And then, and then finally putting this whole package together, we're obviously maintaining the credentialing and doing the negotiations for our clients, but then thereafter, we're helping them to actively manage their portfolio because that's, that's, that's so important. It's like, I would love for you to like me forever and have me on service forever, but the, at the end of the day, it's going to take us about anywhere from six to 12 months to get your portfolio where it can be this round. But then also what we're going to do is going to set you up so that in the next round of negotiations, you know exactly what you need to do to be getting the 150, $175 skilled rates that everyone's kind of pushing for. And then we're also building these clinically integrated networks. We have a handful of them and we have different models for it. May or may not have one in your state, but the best way to get ahold of me, go check out our website. It's yieldhealth IO. And you can see all the services that we provide, what it's gonna look like from a cost perspective. We've, we've set this up so there isn't a huge upfront financial commitment. We're not gonna just ask you to pay us a bunch of money to produce you a bunch of reports that you can't read and that you don't know how to actionize. We're gonna set it up so it's gonna be, it' to be a clear, clear roi. And if you're, if you're serious about wanting to, to get some of this work, let's jump on a call. Takes me 20 minutes to walk through what we do, and I even have a really cool calculator that can show you the ROI on the investment. We're getting six to 10 times the ROI for providers. So really excited, obviously, Hannah, about the work that we're doing here.
• 44:30
  Speaker B: Me too.
• 44:31
  Speaker A: Well, thank you. I appreciate that. You can also just shoot me an email. You can reach me through the website or you can shoot me an email at joeyieldhealthio. We'll set up that consultative call, I'll put a proposal together, and we can talk about how we can get you to where you need to be.
• 44:46
  Speaker B: Is there information on the website about the clinically integrated networks too? Or is that a separate.
• 44:51
  Speaker A: No, there is, there is.
• 44:52
  Speaker B: Okay.
• 44:53
  Speaker A: There's not named identity locations or anything like that, but if you have interest in a network and you have a state that you, you're in a state that could viably hold a network, I mean, there's opportunities there because then what we can do is bring multiple providers together to start the network and kind of go from there. We just. In order to, to do it, we need, we do need to have some community partners to make it work. But that's a great. That does. Obviously that's a longer Runway. Generally takes us a year to set up the network and then we can go out and negotiate, obviously working with providers one on one. It takes us 30 days to do all the analysis work and then, you know, by day 31 and thereafter, we're able to start contacting, contacting payers. So it's a different timeline. I can tell you definitively. I usually can do 5 to 15% increases on a single contract inside of a network, you're looking at contract increases of about north of 25%, typically 25 to 40%. So totally different economics. But what you're effectively creating is a little ecosystem to where you're partnering with the health plans with a bigger group. There's a quality program component to it, so it's not the same animal, but it does get you a lot better results on the rates.
• 46:10
  Speaker B: Can you like, name off the states that already have them?
• 46:14
  Speaker A: Yeah, so, so Oklahoma, they have, they anchor the Southwest Care Partners network. That is a live network that's moving. Texas is going to be coming into that. That network fairly soon and some of those other surrounding states. Kansas has its own thing going on, but those other surrounding states. If you're in one of those states, contact me. I'd love to talk to you. And then we've got another project in the Midwest through Michigan. That is of course, there's the Ohio network. That network I no longer managed. I did build that net, build that network. So if you're in Ohio, that's an opportunity. And then up in the Northeast, a couple states up there looking to. And we can, obviously, the sort of angle we're taking on this is if we can work together with multiple states, that obviously helps, but it's the insurance market is state by state, so you don't have to do it that way. It just helps with the national conversations. I believe in that actually more so than going at it alone. But, you know, obviously the timing of doing something now versus, you know, waiting a year or two years is. Is important consideration.
• 47:25
  Speaker B: Yes, for sure. Well, I really appreciate the work that you're doing and you've been also a great resource for me and for our client. So I appreciate that love for people to reach out if they are interested in this conversation. And I think you should be interested in this conversation if you're a home health agency. Pull out those contracts tonight, dust them off, look at them, get your highlighter out, see what you can find and then reach out to Joe.
• 47:51
  Speaker A: Absolutely.
• 47:52
  Speaker B: Thanks, Joe.
• 47:53
  Speaker A: Thanks, Hannah. I appreciate your time.