The LTC Provider’s Playbook: Q3 2023 Edition

What’s Coming in MDS 3.0, How MA Enrollees Use SNFs, and Where RCM Software Falls Short

In this quarter’s LTC Provider’s Playbook, we take a look at forthcoming changes with the updated Minimum Data Set for skilled nursing facilities (SNFs), the data showing increasing Medicare Advantage (MA) utilization in SNFs, and where RCM software is falling short in long-term care. 

Stay ahead of the curve and be prepared for what’s ahead.

MDS 3.0 Comes into Play in October

Changes to the Minimum Data Set (MDS) go into effect in October, with several changes to definitions and data collecting requirements that are especially pertinent to skilled nursing operators. Among the most significant changes, MDS 3.0 requires more data to be collected from residents directly. MDS 2.0 was critiqued for disenfranchising residents by failing to collect important information from them directly. 

In section GG, the measurement of functional status and goals of residents in their self-care, mobility, and communication abilities will directly impact reimbursement. This change replaces section G and will require staff to be trained appropriately to accurately document residents according to the new definitions. 

As it stands, incorrect or missing codes can mean lost reimbursement. MDS 3.0 adds some complexity to coding that will further emphasize the need for proper documentation in facilities. Fluency in MDS coding is essential to receiving proper reimbursement.

Also changing in MDS 3.0:

  • Social determinants of health (SDOH) will be addressed in sections A, B, and D.
    • These are the conditions in places where we work, live, and recreate that impact a wide range of health risks and conditions.
    • This reflects CMS’ commitment to understanding the impact SDOH have on people’s mental health, such as isolation.
  • Clarifications around resident elopement.
    • MDS 3.0 includes more specifications around what kinds of behavior constitute harm to a resident when they leave a facility improperly or without authorization.
  • More emphasis on collecting racial and ethnic data directly from residents.

Accurate MDS coding is vital to proper reimbursement for every facility. Staff must be properly trained on the new requirements as correcting for improper coding can be near impossible for a variety of reasons, including the reliance on resident self-reporting at specific times during their stay.

CMS Releases Data on MA Usage in SNFs

CMS recently released data on SNF usage by MA beneficiaries from 2016 to 2019, showing rising rates of use of SNFs by 2019. 

Medicare Advantage (MA) plans represent a particularly healthy opportunity for skilled nursing operators with over 900 plans being offered in all 50 states. Getting in-network with these payers and securing profitable terms, however, requires experience and expertise. Having this type of expertise on hand brings obvious benefits as increasing enrollment in MA plans presents an increasing opportunity to capture more referrals.

783,157 MA beneficiaries used SNF services with at least one stay nationally in 2019.

In 2019: 

  • 47.5 SNF stays per 1000 beneficiaries
  • 945 SNF days per 1000 beneficiaries 

In 2016: 

  • 43.3 SNF stays per 1000 beneficiaries
  • 992 SNF days per 1000 beneficiaries

Since the introduction of MA plans in 1997 as Medicare+Choice, enrollment has seen a continuous rise. In recent years, with the addition of supplemental benefits and well-executed marketing efforts on the part of payers, enrollment has spread through regions with great success. Compared to traditional Medicare plans, bundling services under a single MA plan makes finding services far simpler for enrollees.

Enrollment in MA plans is expected to exceed 60% by 2032.

For operators who are willing to take on more residents covered by value-based care (VBC) plans, becoming a go-to quality skilled nursing provider could mean a dependable, long-term source of referrals. One pain point for providers is the perception that reimbursement levels are lower in VBC versus fee-for-service (FFS) plans. Those willing to accommodate well-designed plans could see substantial benefits in long-term relationships and a stronger regional presence.

RCM Software Can’t Fix Every Problem in Billing Offices

Creating concrete billing, AR, and collections processes in your back office is essential to thriving when operators have a myriad of other challenges to solve in today’s industry.

In a previous article, we detailed why even the right billing software isn’t the fix-all your revenue cycle needs. The fact is, long-term care is a uniquely complicated industry. When dealing with Medicaid, Medicare, and private payers, there is a tremendous amount of regulation that requires accurate, timely billing processes and the ability to address denials as quickly as possible.

While technology can solve many of these problems, it can be prohibitive for operators to invest significant sums to create the right technology for their facilities.

For most operators, supplementing in-house billing teams with off-the-shelf software can only achieve so much. At LTC Ally, we constantly review readily available tech and have consistently arrived at the conclusion that designing our own solutions has been the only way to seamlessly and consistently manage billing, AR, and collections for thousands of facilities. Doing so came at no small price, but the results have been practically priceless for our partners.

On average, our RCM department helps facilities increase cash flow by 15% in 6 months.

Finding the right partner to manage your revenue cycle can help clean up processes, bring stability to your operations, and give your facilities a strong financial foundation to provide essential, high quality care. If you haven’t considered outsourcing to experts in billing yet, you could be missing out on increased revenue and better reimbursements that support every other facet of your facilities’ operations.

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Founded in 2006, LTC Ally serves the long-term care industry with an unbound dedication to improving back office and financial operations. With a mission to reduce burdens and increase peace of mind, LTC Ally set out to revolutionize the way facilities handle their revenue cycle management. With a full suite of financial, case management, and contracting solutions for healthcare providers, LTC Ally is your partner in long-term care and skilled nursing.

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