Given increasing complexities in payment systems and intensifying financial pressures, more nursing home providers are hiring leaders with a specialized and sophisticated focus on reimbursement.
Even smaller operators are seeing the value of these positions, which demand a mix of financial and clinical acumen, and a C-suite mindset.
Valerie Taylor, for one, became a corporate Medicaid specialist for CCH Healthcare a couple of months ago, having previously served in a similar capacity for SavaSeniorCare as a case mix specialist. Having one person wearing too many reimbursement hats could leave money on the table, with the increasing complexities of the case mix reimbursement system, she said.
However, even as the specialized role is gaining more attention in the industry, the case mix specialist can be a nebulous area of need for some nursing homes at the moment.
“My title says corporate Medicaid specialist because that was the only title they could think of – they never had anyone in my position with this company before,” said Taylor, adding, however, that due to the role’s novelty at smaller companies, “I also work on quality measures.”
Still, the reimbursement system has gotten “so vast” with add-ons and incentive points, and variation from state to state for Medicaid reimbursements, that Taylor said a case mix specialist has become almost necessary.
“The reason the larger companies would have a specific person is because they span multiple states,” said Taylor. “Each state has different rules. You would need someone that could know these different rules, where the smaller company might just be based in one state.”
Moreover, some operators will still prefer to assign the reimbursement specialist’s role to someone with dual skills.
Linda Humbert’s technical title with Illinois operator Lutheran Life Communities is vice president of ancillary revenue. But she is also a registered nurse (RN) and a licensed nursing home administrator, with experience in operations and business development. She says the Minimum Data Set (MDS) is still a big part of her role. Humbert looks for revenue and opportunities to diversify in the senior living population.
Humbert says her position entails deep knowledge of a region’s regulatory environment.
“In the locations that we are serving, are we aware of what the regulations are for capturing revenue and the mechanisms? How do we translate that to what our nurses and our therapists and our team is doing every day – and is our software capturing it? Are we doing it efficiently? All of that is part of my role,” said Humbert.
And sometimes, if the role can’t be fulfilled from within a facility’s current staff, then nursing homes are compelled to hire people from outside the organization.
Operators contract with consultants for such services, especially MDS consulting, added Humbert. Or, a consultant is brought in to help the in-house person.
Thomas MacDonald, president of Axis Healthcare Consulting, said his team helps operators with MDS issues if they don’t have the requisite expertise.
“If you can bring that [role] in-house, and if you can justify the cost of another person, I think it makes a great deal of sense to do something like that,” said MacDonald. “But finding the right people, and making sure that you can afford those people, that’s a whole different story.”
An evolving corporate role
Humbert says operators seeking to fill these highly specialized reimbursement roles need to have a C-suite mindset.
“I think a strong MDS coordinator could do my role, but there are other skill sets they have to have,” said Humbert. “That would be more of a willingness to go out and explore proactively the changes that are coming and then help senior leadership prepare and know what that means to the organization.”
This person would need to know what Medicaid changes would mean for budget planning. The role would require the employee to answer questions such as whether the company should adopt a new strategy and if the organization needs to improve the quality of care by moving forward in services delivery options or otherwise, Humbert said.
MacDonald said clients have tried to pull their MDS nurses in too many directions as workforce capacity has become strained, taking them away from their primary responsibility, but when that happens it could cost the company reimbursement dollars.
“A lot of people look at it as a clinical role,” MacDonald said of the MDS coordinator. “And yet, in working with our clients, we were talking to them about the importance of really looking at it as a business role, a finance role, because that’s really what it’s all about. Yes, you need the nursing background, but this is a finance role.”
Coupled with the C-Suite mindset, these reimbursement specialist roles will likely be C-Suite positions, consultants or a mix of the two, at least for smaller operators.
Smaller operators are pushed to copy their counterparts because of market conditions, besides the new regulatory environment.
“Typically the for-profit larger operator had to report to their shareholders. They had to really be exceptional,” said Humbert. “Smaller operators were expected [to deliver a return] but maybe the margins weren’t pushed as high.”
Today, smaller operators are looking at inflation and workforce issues, said Humbert, and figuring out how to weather the storm. They’re making sure they’re “running in the black and not the red” by bringing in consultants and making sure they’re doing all they can do in terms of maximizing reimbursement, she said.
Moreover, large companies like Sava wanted someone like Taylor to oversee and keep track of Medicaid, with more than 75% of their case mix being Medicaid beneficiaries. Smaller companies up until this point, she said, could manage with their existing MDS coordinators, but growth has prompted CCH to bring on more reimbursement oversight.
CCH went from having 14 buildings at this time last year to 28 facilities across Ohio and North Carolina, she said, and is still growing.
Sava, by contrast, had eight case mix specialists ensuring adequate Medicaid reimbursement for at least 12 states, Taylor said.
It pays to know when a facility needs to adjust an assessment reference date (ARD), for example.
“Your building has the potential to lose the reimbursement that they’re due,” said Taylor. “You’re still providing that higher rate of care, but you’re going to get paid lower because of the date that’s on the MDS. If you don’t have someone that’s familiar with case mix, and the rules, you can lose a lot of money.”
Maximizing reimbursements
The complexity of the case mix varies from state to state.
“Each state has something different that they require, something that changes your reimbursement,” said Taylor. “It really helps a company to have a dedicated person to know those things and be able to catch that.”
North Carolina has perhaps one of the simplest case mix systems, Taylor said, being on RUGS 3, one of the oldest Medicaid systems.
“That was the first MDS system that came out. It was pretty simple to do. You knew how to capture it, you knew how to move things around. It’s pretty cut and dry,” said Taylor.
Meanwhile, other states like Tennessee require providers to enter the end of therapy days. Also, states like Georgia have different rules for conducting mental status assessments, she said.
Humbert brings in a consultant occasionally, or an informatics person to look back at Lutheran Life’s software for capturing the highest level of reimbursement.
And while the MDS is critical to this assessment, Humbert also looks at what the surrounding community needs in terms of other services, which would also enhance Lutheran’s revenue while circumstances are making things “tighter and tougher” for skilled nursing facilities.
Humbert also noted inflation and workforce shortages as the obvious headwinds for the industry.
Prior to her onboarding at CCH, Taylor was a case mix specialist for SavaSeniorCare until the company’s dissolution was announced in December. She started out as a floor nurse and eventually worked her way up to an MDS nurse position with a regional role for the company.
With Sava, Taylor would come in if there was a new MDS nurse that didn’t know the difference between Medicare and Medicaid, the different assessments that needed to be done for each, or if there was a facility that was having trouble with its Medicaid reimbursements.
“At Sava I did more education. I would go more to the buildings in the beginning … probably once or twice a month, and do education with the staff,” said Taylor.
Taylor would also review everything in the facility system, hold webinars and conference calls on reimbursement.
“You want to make sure that you set your MDS assessment correctly to capture for Medicaid, because you want to capture different things, reimbursement wise,” said Taylor.
If a facility is capturing what they’re providing to residents and making sure everything is accurate, audits will be smoother down the road, she said.
Companies featured in this article:
Axis Healthcare Consulting, CCH Healthcare, Lutheran Life Communities
