Resources on the Brink

Revenue capture has always been a very nuanced, specialized and time-consuming task. Led by MDS and supported by cross-functional teams, the process for many SNFs includes daily or weekly UR meetings, manual chart reviews, post-MDS audits, triple-checks and much, much more. All of which are driven by people—administrative staff time, diligence and rigorous effort. Unfortunately, due to turnover, burnout, staff shortages and the added work of COVID-19, those resources and processes are being pushed to the brink in many SNF settings nationwide. MDS nurses and case managers are working the floor and wearing even more hats. As a result, corporate reimbursement specialists are covering open positions in multiple buildings, while a growing number of nurses (with and without experience) are being pulled from their post to fill MDS roles more than ever before. These growing challenges have created a tenuous environment for maintaining an adequate level of revenue integrity for operators.    

Growing Reimbursement Complexity

This comes at a time when insurance complexity, across all payers, is at an all-time high. Each operator is navigating a multi-payer system unique to their region including Managed Care, traditional Medicare and Medicaid. On a county-by-county level, there are 30% more managed care plan options than there were two years ago. Traditional Medicare’s move to PDPM was a daunting task—even for the most seasoned MDS nurses and a bigger ramp-up for new ones. On top of that, state-based Medicaid programs, whether driven by a RUGs grouper, managed care or some other model, aren’t the easiest systems to pick up either.

With this multi-payer model, the list of administrative tasks remains long, and every item is equally important. There are different rules for Medicare, Managed Care, Case Mix, Quality Measures and OBRA/Care Planning that all must be followed and coordinated. There are more than seven different manuals [RAI Manual, Quality Measures Manual, Medicare Benefit Manual, Managed Medicare Benefit Manual, SNF QRP Manual, SNF VBP Manual, Five Star Manual] for MDS nurses to adhere to for instructions, interpretations and rules outside of the volumes of general LTC regulations. It’s not enough to simply have them laying around as reference manuals—real expertise is required to be able to act on them across situations.

Resource Limitations + Growing Insurance Complexity = Reimbursement Risk

Consider how this complexity, which is only growing, coupled with numerous manual tasks, burnout and turnover, creates revenue risk. Whether you acknowledge it or not, your reimbursement is at risk because manual tasks will always break down at one point or another as complexity and volume rises. Here are a few examples of the opportunity lost due to potential revenue leaks:

Given the complexity, required diligence and time-consuming nature of reimbursement, these missed opportunities may result from a myriad of things such as:

• Simple coding mistakes.
• Poor pre-admission workflows and data sharing among admissions, MDS and case management.
• Accepting the default managed care level from the case worker versus advocating for a higher level of care based upon the contract.
• Overlooking timely condition changes that may lead to an interim payment assessment (IPA), managed care level update or Medicaid RUG change.
• Missing managed care exclusion opportunities.

Helpful Tips

Considering your mix, incremental improvements can make a big impact. Here are a few things you can do today.

• Timeliness matters – for each payment model, timely capture is absolutely critical. Let’s consider a significant change scenario where you have a patient condition change outside of an assessment window. Under PDPM, this will often lead to an IPA opportunity. For managed care, there may be a level increase, depending upon the plan. In certain states, this should trigger a new ARD and CMI increase under a Medicaid RUG program. Unfortunately, none of this happens if you’re not staying on top of your case load and constantly watching for patient condition changes. Although acting on all these rules, in a resource-strapped environment, is a tough ask, it’s important to put processes in place that enable you to avoid revenue loss.
• Know your rules – this comes down to training and diligence. It’s one thing to be able to complete a MDS assessment or continuing stay review for a managed care case. But it’s another thing to know that you need prior approval on an expensive drug or service to be able to pass that charge along to the Managed Care company, or, that the additional NTA you spot in the patient’s chart on day 18 changes the NTA score and would improve your reimbursement. Creating handy cheat sheets and reference guides for all three major payers is very helpful.
• Utilize external resources – to combat staff-related strains. There are many resources for MDS support from outside agencies, corporate consultants, consulting firms and associations. Companies like Richter are ideally suited to provide a variety of consulting services such as: training new MDS coordinators, assistance with workflow-related efficiency planning, guidepost-MDS audits and much, much more.    

• ---

  Technology can help – MDS scrubbers are great for pointing out assessment-related coding mistakes but are not well-suited for timely capture and don’t provide much help with your managed care related needs. They also tend to be very reactive—working solely off the MDS that you just worked hard to complete. Luckily, there are new high-tech software solutions in the market that satisfy the proactive need for timely Artificial intelligence technology is here today to help supplement human expertise and save a ton of time, because we ultimately can’t bill for what we don’t see and capture in the clinical documentation. (Shameless AI/MedaSync Plug)

The takeaway here is that efficient revenue capture is more important today than ever before, especially given the immense financial pressure many SNFs are under. Without it, we can’t empower and financially support our passionate and amazing teams to keep them going and caring for the patients that need our help. Payment complexity and resource challenges may continue to intensify—and, more than ever, SNFs need the right workflows, tools, technology and support to navigate this ever changing landscape.

About Guest Columnist: Ryan Edgerly is the CEO and Founder of MedaSync Software. Medasync is the skilled nursing industry’s first proactive reimbursement software driven by AI, to help operators ensure revenue integrity across all payers—Medicare, Medicaid and Managed Care.