Kim Majick wasn’t even looking for lost money.
But she found it: an under-reimbursement of $6,000 for wound-care work.
“I just happened upon it because I was in the chart digging for something else,” she says.
Majick is Chief Development Officer at skilled nursing provider Cincinnati-based Carespring Healthcare Management, which operates 18 skilled nursing properties. As with most of the sector, Carespring has faced both an ongoing workforce shortage and a referrals bottleneck from the hospital and other care settings.
To combat 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 level for all services they provide.
“We are a pretty high-skilled nursing utilization company, so we have a lot of rehab-to-home customers,” Majick says. “Multiple insurance contracts are all written with a different payment language. Some are paying by levels, some are paying through Medicare. The ones that pay levels all differ in how the contracts are constructed and what qualifies for each level.”
With this added complexity on top of traditional Medicare and a high population of Medicaid patients, reimbursement misses can unfortunately become more frequent.
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 which does not get communicated and they might simply miss it.
In any case, staff should take action to request increased reimbursements, particularly 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 the Anthem contract, but you’re only a level two in the Humana contract,” she notes. “Being able to keep all of that information in your brain was complicated.”
Carespring’s case management team has five clinicians, but each does 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 for admitting patients.
They’re reviewing “thousands upon thousands” of clinical documents to assure they’re getting the right level of reimbursement and patient authorization. Management would have to sit down and talk about individual cases, maybe doing a sample of four or five cases for review.
“Maybe you’d find the problem, but there was just no way to have good 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. While not initially a major focus for Carespring, improvement in Medicaid CMI capture resulted in a $45,000 reimbursement uptick in just the first 90 days.
Even in these more typical cases that most MDS nurses consider their bread and butter, resource strains and communication issues can still result in under-reimbursement. With Medasync, Carespring clinicians gain assurance that their services are being properly reimbursed 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 payment parameters, levels of reimbursement and what clinical services qualify for each level. The software also scrubs the patient’s medical record to see if direct care workers are actually documenting and providing services at the right 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 database they can review for under-reimbursement alerts, and financial software can be updated to assure staff is billing at the appropriate level.
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 and 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, new clients getting the skilled nursing care they need and improved occupancy.
“You’re just going to be able to process more incoming cases because you’re not going to have to spend as much time processing the ones you already have,” 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 and 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, visit medasync.com.
