4 Ways to Protect HCBS Providers During the Transition to Managed Medicaid

Copyright 8.12.2014: Scientific Cowboys – Nancy C Everitt, PMP

As an industry are we placing Home and Community Based Services (HCBS) providers at risk during the transition to Managed Long Term Services and Supports under an MCO? You bet we are.

However all is not lost. It’s critical to focus on what we can do to protect these providers who often have no managed care expertise.

Read on for 4 ways to enhance implementation and minimize implosion for HCBS providers.

  1. Simplification
  2. Financial
  3. Education
  4. Resources

1. SIMPLIFICATION: Managed Care and Credentialing

Many of us in the Scientific Cowboys community have several decades of managed care negotiations under our belts and therefore contracting for HCBS appears simple and basic.  Stop…think back to your first managed care contract and the uncertainty of the language, intent, requirements etc. Now think about how you as a small organization with limited resources will implement oftentimes complex requirements.

As we move forward with HCBS providers it’s critical to remember that while some are large, regional and/or national organizations; 95% of HCBS providers are small organizations or individuals.

Given this reality, think about how the contract and requirements can be simplified in approach and interpretation to assist new managed care entrants with limited resources.  On a positive note I have seen some simplified credentialing processes and lower insurance requirements.

2. FINANCIAL: Prompt Payment, Advocacy, Interim Payments

Timely reimbursement is a contributing factor to the success of an HCBS provider. Most providers do not have 6 months of reserves and other payor sources to offset a slow down in receipts. In some states there have been claims problems that have been detrimental to these providers resulting in closure due to cash flow challenges.

During implementation consider additional resources, training, interim payments and assistance for these at risk providers for the first year.

3. EDUCATION: Webinars, E-learning Modules

Managed Care is like English as a Second Language (ESL) for those who speak it; it makes sense – for others its foreign. Consider additional Provider Relations seminars; at seemingly odd times since the provider first provide care.  Basic and more advance topics should be provided. There will be a learning curve.

Plans should take some time to walk through the contract, provider manual, quality requirements etc. This will be time well spent to strongly integrate these providers within the plan and managed care environment.

Most HCBS providers will not have dedicated managed care resources.

4. RESOURCES: Dedicate or Outsource

At this point you as a plan executive may be thinking “No way!” we don’t have the time for this extra attention. Understood, then outsource.

The CENTIPEDE Health Network is just one example of a national HCBS network and service bureau to support and manage the relationships and education of HCBS providers. There will be other options in the future.

The only option that is unacceptable is… no action.



Home and Community Based Services are the “x” factor for empowering individuals to remain in their homes as opposed to external settings. As an industry, we need to step up and ensure that these providers survive and thrive. Yes, it’s enlightened self interest. We can decrease costs, expand the coverage of a healthcare dollar and provide an enhanced quality of life.

As managed care experts we have a responsibility to be proactive in integrating what I refer to as “the last frontier of healthcare” still unmanaged and a bit chaotic. HCBS integration is a vital next step to a full continuum of care. This will be threatening to many traditional providers as the dollars shift, but that’s okay… it’s what a healthy market does.

Movement via disruption creates innovation.

Take a few moments and consider how your organization will step up and assist HCBS providers in becoming a vital part of Managed Care and global payor solutions in the future.

It’s a worthy investment.


About the Author:

Nancy C. Everitt, MBA is the President and CEO of HEOPS, Inc. and Editor in Chief of Scientific Cowboys. Ms. Everitt is lead strategist to Clients’ on the design and fulfillment of patient access solutions such as network development and provider engagement, quality analytics, Medicare Advantage STARS strategy, disruption analysis and mapping. Ms. Everitt has been involved in the strategy of each engagement and provides significant perspective on industry best practice.

In addition to serving as Editor in Chief on Scientific Cowboys, Ms. Everitt is a frequent contributing writer to the publication sharing real world advice and operational insights on process and performance improvement. Questions on this article may be addressed directly to neveritt@heops.com.



It’s not about activity, it’s about results. However results alone are not enough, in Drucker’s words: to be effective you must complete the right things. — Nancy C. Everitt

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