As with most of the sector, Cincinnati-based Carespring Healthcare Management has faced ongoing workforce challenges, and their share of insurance and reimbursement complexity. Carespring operates 15 skilled nursing properties between two states, Ohio and Kentucky, and juggles a variety of managed care payers as well as differing Medicaid systems.

“Carespring offers a superb rehabilitation product, serving a high proportion of rehab-to-home customers,” says Kim Majick, Carespring’s Chief Development Officer. “Multiple insurance contracts in multiple regions are all written with a different payment language. Some are paying by levels, some are paying using Medicare methodology. The plans that pay levels all differ in how the contracts are constructed and what qualifies for each level.”

With these added complexities — on top of traditional Medicare structure, a high population of Medicaid cases and resource strains — ensuring that facilities are properly reimbursed by payers is increasingly complicated.

To combat all of that, operators including Carespring are embracing simple, AI-based software to solve these pervasive problems. Carespring, for one, is partnering with software firm Medasync to streamline manual tasks for its clinical staff while also ensuring that they receive the appropriate reimbursement aligned with all the services they provide.

How rising reimbursement complexity and tight staffing levels created challenges

Carespring’s problem, Majick says, was simple: despite clinicians providing the best care and patients meeting all criteria, the organization was not always receiving the appropriate level of reimbursement.

Under-reimbursement happens in a few ways, she says. The team could potentially miss information in clinical reviews even prior to the patient being admitted to the facility. Clinicians might not record information from a hospital document, deeming it irrelevant. Or a condition change occurs during the stay which does not get communicated and they might simply miss it.

In any case, staff should take action to capture reimbursable opportunities where appropriate, which may mean a new strategic ARD for a Medicaid case, an IPA for PDPM or a level request for managed care beneficiaries. For an organization with multiple managed care contracts, having them all memorized is impossible, Majick says.

“If you have a stage three wound, you’re a level three in one contract, but you’re only a level two in another contract,” she notes. “Being able to keep all of the plan complexities straight is difficult.”

Carespring’s case management team has five clinicians, each processing and reviewing 90 to 100 cases a month. Instead of spending that time with patients, clinicians are communicating with insurance companies, either submitting documentation to support extended stays, or getting pre-authorization to admit patients.

They’re reviewing “thousands upon thousands” of clinical documents to assure they’re getting the right level of reimbursement and patient authorization. Oversight of performance is challenging as auditing a few records may not uncover the potential opportunities.

“With case reviews, perhaps you’d find a problem, but there was just no way to have good, consistent oversight over all of the potential opportunities,” Majick says.

“Humans may miss that. The tech does not.” — Technology is a reimbursement safety net

No one wants to be left in the dark about being reimbursed for their care efforts. With Medasync, Carespring clinicians gain assurance that their services are being captured across all payers.

“We came across Medasync as a solution to that problem, as a way that we could use tech to scrub data and alert us when patients are in a different level than what we believe them to be,” Majick says.

Medasync’s technology stores contract parameters, levels of reimbursement and what clinical services qualify for each level within a specific managed care contract, while also containing rules for individual state Medicaid and Medicare PDPM. The software also scrubs the patient’s medical record to assure that direct care workers are consistently documenting and providing services at the appropriate level.

“We might believe that somebody is a level two, but per our therapy minutes, we are providing therapy that qualifies them for a level three,” she says. “Humans may miss that. The tech does not.”

Now, Carespring has a dashboard they can review to properly align service delivery and clinical documentation with the financial output. Even in more typical cases such as long-term Medicaid and traditional Medicare, Medasync has helped the clinical team proactively pinpoint patient changes important for new ARDs resulting in Medicaid CMI improvements and PDPM IPAs.

That gives staff “extraordinary bandwidth” to provide direct patient care instead of spending hours auditing documentation. Medasync has listened to clinician advice to make its software better for the sector, implementing suggestions along the way.

“Their openness to product enhancement, listening to the providers and what we need, that’s really made the relationship beneficial to both sides, but certainly to us,” Majick says. “That collaboration, it’s so appreciated in a partner — particularly a tech partner.”

Serious time-saving benefits for staff, peace of mind for management

For Carespring, working with Medasync translates to faster response times for new authorizations, less staff time on manual documentation reviews, new clients getting the skilled nursing care they need and improved occupancy.

“You’re going to be able to process more incoming cases because you’re saving time using technology to guide you,” Majick says.

“It’s all important, but as caregivers, what’s most important to us is that we get to focus on the patients and the care delivery, not on assuring we’ve sent the right document to an insurance company. This just takes that worry away from me.”

This article is sponsored by Medasync, which offers simple AI software for skilled nursing facilities to help improve revenue integrity across all payers, automate pre-assessment workflows and reduce staff time. To learn more about Medasync and their Carespring success story, visit medasync.com.