Blue Sky Therapy Blog

What you need to know about Managed Care & PDPM: Ask The Experts (With Webinar)

by Blue Sky Therapy

By: Lisa Chambers, MSCCC, SLP, CHC

COVID-19 has changed the landscape of long-term care for the foreseeable future for everyone from ownership to admissions. It is imperative to ensure you understand the changing dynamic with managed care and how to properly manage your cash flow.

The industry has seen a 58% increase in managed care organization (MCO) enrollment, according to and NetHealth. The reason for this can be boiled down to a few reasons, but one stands out: consumer convenience. Consumers want one plan that covers all their Medicare: Parts A, B, D as well as other non-traditional insurance benefits. In the state of Ohio, 35% of Medicare beneficiaries enrolled in Medicare private plans in 2017 and Medicaid MCOs are growing at a similar rate.


These plans are often managed by for-profit firms including major commercial payers such as United Healthcare and Aetna. While Federal law requires that states establish network adequacy standards, state have a great deal of flexibility in doing so. This includes their payment turn around times and the overall reimbursement rates for the provided coverage. Both Medicare and Medicaid MCO reimbursement tend to be lower than traditional plans and they can enforce additional requirements of providers.

According to the Kasier Family Foundation, states are also implementing quality initiatives within an MCO contract and linking these to a variety of focus areas with performance measures. Performance measure focus areas include:



With the rapid expansion of Managed Care Organizations, providers need to be masters of what these plans mean to their bottom line of cash flow. Thank you to those joined us for our webinar on August 19, 2020 to learn about these plans, tips for accepting patients with MCOs, and ensuring that you are meeting all MCO performance metrics for maximum payment. 

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