Tips and takeaways: What SNFs should know about CMS mandated enrollment revalidation

Read this if you participate in onboarding healthcare providers. 

The last several years have certainly been challenging for healthcare. Fueled by the COVID pandemic, increased provider burnout is a huge issue that has organizations grasping to keep staffing levels high enough to provide exceptional patient care. Physician turnover (per physician) has been estimated to cost an organization between $400,000 and $1,000,000 when factoring in recruiting costs and lost patient billing revenue. For smaller organizations, that can be a major challenge. 

The US Department of Labor Statistics estimates that by 2030 the healthcare industry will grow more than 16%, adding over 2.6 million new jobs. With 5% of physicians turning over each year (this number doubles when including physician assistants and physical therapists) and 61% reporting burnout, organizations should take steps now to minimize attrition and ensure a stable clinical workforce. 

Provider onboarding as a retention strategy

Provider onboarding is a window into an organization’s culture and is the foundation of the provider experience. During this period, action and inaction, both real or perceived, will set a new hire’s impressions of the organization. A positive experience can ensure early buy-in from new providers, helping employers improve retention rates and provider satisfaction. 

For many organizations, onboarding and orientation are the same. However, there are differences. Orientation is a one-time event for tasks (i.e., completing an I-9 form, new-hire paperwork, discussing benefits). Onboarding is an experience that begins once a provider has accepted the position and will last at least 90 to 120 days. The provider will have contact with human resources, IT, the medical staff office, and finance/revenue cycle departments to gather much of the same data (e.g., licensure, CV, NPI, and other demographic information).

A well-organized and coordinated organization can reduce the number of times a provider is asked for the same information or documents. Clear communication and centralized points of contact and processes are critical to a smooth process. To help organize onboarding, you can download our Provider Onboarding Checklist.

Ensuring you have all the information and documents your organization will need from the provider for privileging, third-party payer enrollments, HR, and IT has additional benefits beyond provider experience. Preparing new providers to participate on a payer panel linked to the organization can be an exceptionally lengthy process, often exceeding 90 to 120 business days. Additionally, if your organization participates with a large volume of managed Medicare and Medicaid payers, gathering the information and beginning the process early through an efficient onboarding can ensure you decrease write-offs of billable services to the dreaded ‘provider not credentialed’ denial code.

Provider onboarding and timely, quality patient care

Equally important is the connection to delivering timely and quality patient care, as the third-party payer process directly impacts these activities. An unenrolled provider lacks the ability to order, prescribe, and refer. This necessitates additional touches, resulting in breakdowns in the workflow that can lead to unnecessary expense and provider dissatisfaction. The provider enrollment process must be initiated early, and frequent communication with all involved parties can alleviate any issues. 

Organizations should offer providers robust revenue cycle-related clinical systems training as part of the onboarding process and create a mechanism to identify potential errors that may lead to write-offs and compliance risks. Provider entry errors can result in a claim ending up in a work queue, never to be identified, submitted, or paid. You can mitigate revenue loss by monitoring entry errors and providing additional training. Wasteful workforce expenditures are created through revenue cycle teams chasing information to be corrected, causing rework. Education for providers and everyone supporting them in operations will also go a long way toward reducing errors, increasing satisfaction, and minimizing barriers to care and collection challenges. 

If you would like more information or have questions about your specific situation, please reach out to our credentialing consulting team. We’re here to help. 
 

At first glance, the healthcare patient check-in process seems straightforward. But when examined through the lens of your revenue cycle and patient experience, it’s one of the most important interactions for your team to get right.

Several key elements must be taken into consideration to create a smooth and simple patient check-in. Patient satisfaction is the tip of the iceberg. You want your patients to have a great experience that is efficient, easy-to-understand, and doesn’t create billing headaches for them later on. The good news is that the same techniques that give your patients a good experience also form the basis for an optimal revenue cycle. Developing this process starts with the undersurface elements that patients never see.

Scripting for patient access teams

Communicating clearly, consistently, and positively is important to put patients at ease, and to make sure that you collect the most accurate and up-to-date information from patients. Doing this correctly up front will save time and will prevent denials and associated workload and revenue loss. The best practice is to establish scripting for your patient access staff and provide training to make sure they are confident in the scripting provided. Here are some examples:

When confirming that patient information is up to date:

Say this: “To ensure your account is as accurate as possible, we require all patients to present a minimum amount of information.”

Not that: “Have there been any changes in your information since the last time you were here?”

Or when connecting a self-pay patient with a financial counselor:

Say this: “Before scheduling your appointment, I will connect with a financial counselor who can determine if you qualify for assistance and will help you understand your financial obligations.”

Not that: “We can’t schedule you until you speak with someone in Finance.”

Developing clear and efficient scripting will give your team the tools to communicate effectively and will help your patients feel like they are well taken care of.

Schegistration: What is it? 

What is “schegistration” anyway? Schegistration is the process of scheduling a patient appointment while also pre-registering the patient at the same time. By gathering and confirming information at the time of scheduling, the in-person check-in process will have fewer steps and will be quicker and easier for both the patient and your team.

Technology: Align your EHR with patient access workflows

Technology, specifically your Electronic Health Record (EHR), can either make your workflows more efficient, or can hinder your patient access staff. It’s important to align your technology platforms with your operational workflows, so it is seamless for your staff to enter and pull up information. It’s also important to have your staff trained regularly on your technology systems so they feel confident that they are using the system correctly and most efficiently.

Documentation: Write it down! 

When you develop new workflows to increase efficiency and the patient experience, it can be challenging for staff to make the change. In a busy office environment, it can also be difficult to train new staff effectively. To make it easy and to create consistency and continuity, it’s important to develop standard operating procedures and to document them thoroughly. Providing easy to understand instructions, including visuals of workflows, will reduce errors, promote standardization, and improve accountability.

Leadership: Reinforce best practice workflows

Keeping workflows optimized takes the whole team, beginning with leadership. The leaders of your patient access team should act as reinforcement when team members learn and complete best practice check-in workflows. Having documentation readily available and providing support and encouragement to team members will help keep your processes running smoothly.

Patient access team collaboration

Establish clear expectations to foster a supportive team environment and facilitate problem-solving and quick assistance. When scripting, workflows, and documentation are consistent, it’s easy for team members to help each other out and support each other when challenges arise.

The healthcare revenue cycle is an intricate system involving interdependent functions. Like an ecosystem, each component plays an important role in the system. The patient access process is just one piece of the puzzle. Optimizing your revenue cycle also includes looking at these areas: coding and compliance, billing, and denial management.

BerryDunn's audit, tax, clinical, and consulting professionals, focused on specific healthcare industry areas, understand the biggest challenges facing healthcare leaders, and are committed to helping you meet and exceed regulatory requirements, maximize your revenue, minimize your risk, improve your operations—and most importantly—facilitate positive outcomes. Learn more about our healthcare consulting team. 

 Read this if you are looking to keep your physicians and other team members engaged.

According to recent estimates, three quarters of physicians are employed by hospitals, health systems, or corporate entities. As a result, leaders in healthcare administration are increasingly confronted with the challenges and opportunities associated with engaging their physician workforce.

What is physician engagement?

The verb "engage" is used in common speech to convey a spectrum of messages and has a wide semantic range. Engage and its word family are used to impart diverse ideas. It can convey a range of meanings, from entering into battlefield combat to the promise of future matrimony. Considering this, the term used in today’s workplaces is not monolithic and its true definition should not be assumed. Instead, organization leaders should be clear on what engagement means to them—and clear about their intentions—if they want engagement to improve physicians’ job satisfaction and attain organizational goals. 

Why engage?

According to the Centers for Medicare and Medicaid Services (CMS), the US spent more than 17% of its GDP in the healthcare industry in 2022. Healthcare organizations are continually challenged to demonstrate improved quality and outcomes while lowering costs. Physicians face higher patient acuity and increasing time pressures, in addition to changing and growing regulatory burdens. So, it comes as no surprise that physician burnout is on the rise. 

A recent Gallup poll found a strong relationship between physician engagement and productivity. Physicians who were fully engaged were 26% more productive than those not engaged or actively disengaged. Moreover, physician care is the key revenue generator for hospitals. According to Merritt Hawkins’ 2019 Physician Inpatient/outpatient Revenue Survey, the average net revenue derived from admissions, tests, prescriptions, and procedures performed or ordered per physician was $2.4 million per year. Succinctly put, physician engagement positively affects healthcare organizations’ bottom lines. 

A model for employee engagement

There exist numerous models for employee engagement. One such model from DJS Employee Research focuses on the six Cs of employee engagement:

• Career: Employees have an opportunity to develop themselves
• Clarity: Employees believe there is an open, honest culture with trust and transparency
• Confidence: Employees have confidence in their leaders and see them role modeling values
• Communicate: Employees participate in decisions that affect their work and feel free to speak up
• Care: Employees feel valued and recognized for the work they do
• Collaboration: Employees feel able to innovate and suggest new ways of doing things

While each one of these Cs could be the topic of its own article, when viewed together they provide a helpful summary of all the components affecting a physician employee’s (now 75%) engagement with their organization. How is your organization faring in these categories?

Why physician engagement efforts fail 

Physician engagement efforts often fail due to an inability to understand the importance of engagement activities and, sadly, a simple lack of effort. When efforts are made, yet fall short, it is frequently a result of three Ms: misalignment, misunderstanding, and missed opportunities.

• Misalignment of vision and goals
  Misalignment arises when a vision is not created and effectively shared, and goals are divergent, as administrators and physicians are not on the same page. The term “physician alignment” is often used inappropriately, frequently to describe strategies of how to maximize organizational outcomes (usually financial). As a result, alignment has come to mean the business relationship organizations have with physician groups, rather than the alignment of vision and goals.
• Misunderstanding and lack of communication
  Misunderstanding arises when time and effort aren’t expended to listen, understand, and confirm clarity in communication. When misunderstanding occurs, even in the presence of a good foundation of shared vision and goals, administrators and physicians may still be at odds. What do organizations want from their physicians? Referrals? Enhanced revenue? Increased patient throughput? Quality, even though metrics may not accurately reflect what is considered to be true quality? Better documentation? No complaints?
  
  Healthcare administrators not only need to clearly communicate their priorities, they also need to make a sincere effort to seek physicians’ perspectives, listen to them, and value that feedback. Lack of clarity leads to poor communication, which undermines collaborative efforts and breaks down confidence, resulting in individuals not feeling cared for and consequently more likely to find career opportunities elsewhere.
• Missed opportunities: Quadruple aim and physician turnover
  Missed opportunities are the unfortunate result of a continued cyclical pattern of misalignment and misunderstanding. They become a cost to the organization, hampering the attainment of healthcare’s quadruple aim: improving population health, the patient experience, and the work life of health-care providers, all while reducing cost.
  
  Perhaps the ultimate missed opportunity is the physician who has chosen to take their career somewhere else because of a lack of attention to the six Cs described above. Physician turnover is extraordinarily expensive. Estimated hospital opportunity costs in 2019 (in terms of lost revenue) range from $175,000 per month for a family physician to $273,000 for an orthopedic surgeon. Additional expenses include new physician onboarding, estimated in 2016 to cost between $200,000 and $300,000 (8), a figure undoubtedly higher today. 

Communication and Clarity

While all the six Cs are important as a framework for capitalizing on opportunities, two stand out as particularly illustrative: Communication and Clarity. Physicians and associated medical staff are highly educated and trained. They have valuable ideas and contributions, yet frequently don’t share their thoughts outside the protected bubble of their peers. Healthcare administrators need to create a safe space for physicians to communicate their thoughts, insights, and suggestions. 

Missed opportunities also result from lack of clarity on the purpose of contemplated changes. Unintended consequences may result. At times, actually implementing a change can itself be a missed opportunity. How often has a change been made to reduce costs, only to result in adverse impact on physicians? 

An example is the large physician group that wants to streamline and eliminate some administrative tasks. Administrators institute use of a new online platform for expense reimbursement, requiring physicians to input information on their own, including scanning, uploading, etc. Administrators may reason because they themselves perform the task routinely, shouldn’t physicians as well? Often too late, they realize, that imposing this seemingly minor administrative burden has yielded unintended consequences. In this example, chasing potential savings through an ill-advised change resulted in negative physician impact, disengagement, and eventually, organizational loss.

Beyond physician compensation

Competitive compensation packages are certainly important, and organizations wrestle with providing appropriate incentives and integrating value-based metrics into their models. Organizations should strive to provide compensation models in which incentives align with values. Equity is important, as is avoiding models that cater to ‘squeaky wheels’ or are prone to special deals.

Organizations should understand that simply raising compensation to above-market levels does not necessarily buy positive physician engagement. Undoubtedly, physicians want to be fairly and equitably compensated. However, it is just as important that physicians feel listened to and heard, proving their opinions matter and that they are valued. 

Words matter, as does professional identity. Physicians want to feel they have some measure of autonomy. Physicians often feel they have no control, sensing decisions are made by others. They perceive private equity firms deciding overall budgets, insurers approving or disapproving procedures, administrators controlling hours, hiring and firing, and staffing without their input. Physicians bemoan lack of organizational power, yet feel they are held responsible for poor outcomes. 

Physicians frequently report disliking and being demoralized and devalued by use of the term “provider.” A Mayo Clinic blog author has emphasized that the word “provider” is a nondescript term that confers little meaning. It does not convey to patients or to anyone else who will be caring for them. It implies that the relationship between physician and patient is one of simple commercial transaction. Titles matter. Imagine a Chief Financial Officer of a hospital being referred to as a “finance provider.”

Physicians care deeply about their patients and providing quality care. Tasks that physicians perceive as taking time and not directly contributing to patient care are not viewed as important. Administrators can avoid potential goal misalignment by communicating their needs to physicians from a patient care and quality standpoint. Goals do not necessarily need to be the same.

Administrators can succeed by framing their goals in terms of what is important to their physicians. While it might be particularly important to a hospital administrator to improve medical record documentation to facilitate coding and revenue cycle management, physicians are less likely to respond to a pure financial argument. They will be more likely to participate in a medical record completion initiative by appealing to quality-of-care issues and the impact of poorly documented medical records on continuity of care, risk management, and the ability for physicians to effectively treat patients post-discharge. 

Improving physician engagement

When seeking physician engagement for a contemplated or planned initiative, it starts with listening. Administrators should hear and understand physician concerns and actively seek their input. Develop a communication plan. Depending on the issue and nature of the organization, communication can take the form of personal meetings, town hall sessions, written communication, or optimally, a combination of all three. Enlisting help from the medical team can be especially useful. In larger organizations, the identification of physician champions can be particularly beneficial to model behaviors and carry messaging to peers. A consistent, clear message is paramount to successful physician engagement.

Through understanding the importance of physician engagement, how it can go awry, and truly appreciating a physician’s perspective, healthcare administrators can build allies, not adversaries, and create an environment of collegiality, cooperation, and collaboration. Success conjures images of wedding bouquets rather than of the battlefield. 

BerryDunn champions a unique approach to the physician-administration relationship. Reach out to us if you would like more information or would like to discuss how to improve physician engagement at your organization. We’re here to help.

This article is a condensed version of our in-depth resource Seven well-being focus areas for a resilient workforce. Download the full report, which includes additional considerations, key takeaways, and real-world best practice examples.

It's important for organizational leaders to understand that employee perspectives on well-being are constantly shifting, as are their expectations from employers. To stay competitive in the recruitment and retention of employees, employers need to stay abreast of the current well-being trends—the ones that have the potential to move the needle in creating a thriving, healthy workforce. We’ve identified and analyzed the top seven trends for 2024 that should be top of mind for employers as they think about the future evolution of their well-being strategies.

Ongoing focus on mental health and resilience

Employers can play a pivotal role in cultivating an environment that benefits the mental well-being of all employees. And just as exercising and healthy eating benefit everyone (not only those with a physical health diagnosis), programs, resources, and cultures that cultivate mental well-being can help improve overall workforce resilience. For example, an environment where there is little to no stigma around mental health challenges and where supervisors and peers respect and openly support mental health self-care will better withstand the inevitable ups and downs that every employee and workplace will experience.

Modernizing financial well-being

Financial well-being begins with a fair and competitive salary. Fair and competitive needs to account for a variety of factors—including pay equity, cost of living, health insurance affordability, and executive pay ratios. Additionally, organizations should be providing employees with the resources, education, and benefits to help manage debt levels, save for the future, and cope with financial stress.

Some ways employers are addressing these needs include expanding benefits to include personalized financial counseling, credit/debt counseling, or implementing new incentives to encourage positive financial decisions. Other popular considerations relate to easing the burden of childcare expenditures and student loan repayment. For example, the SECURE 2.0 Act allows employers to match 401(k) contributions with employee student loan repayment (among other things). For organizations where pay is a known concern, it may be time to conduct a more in-depth compensation analysis to understand gaps in employee total rewards. https://www.berrydunn.com/news-detail/secure-20-act-of-2022-introduces-key-changes-for-workplace-retirement-plans

Telling the well-being story as part of the employer brand

An employer brand is how employees and job candidates experience an organization’s mission, values, and workplace norms. Workplaces that lead with a visible emphasis on shared values (versus policies and rules) cultivate trust and belonging. Well-being programs can bring organizational values to life—particularly those related to trust, excellence, collaboration, diversity, integrity, authenticity, and work-life harmony.

Consider the existing programs, benefits, and resources as different building blocks of an organization’s well-being story. Cataloging these elements by well-being dimension (e.g. physical, mental, social, financial, and career) and by employee persona (e.g., stage of life, dependent responsibilities, nature of work responsibilities, work environment) can help build a compelling story while also revealing gaps in the well-being strategy.

Download the full report, including key takeaways and best practice examples.

Connecting well-being with other “good for business, good for people” initiatives

Leaders across industries are seeing the business case for organizational strategies around a range of topics, including employee engagement, Diversity, Equity, and Inclusion (DEI), Triple Bottom Line (e.g., Environmental, Social, Governance [ESG] and Corporate Social Responsibility), upskilling, and organizational resilience. While each topic warrants some unique considerations and tactics, there is much opportunity for coordinated initiatives that support multiple goals.

Positioning humans for success in an AI-enabled, not-so-distant future

Generative Artificial Intelligence (AI) was fresh on the scene in 2023 and is already on a fast course to disrupt many aspects of business and work as we know it. From AI-powered personal assistants to chatbots that will write programming code, articles, and resumes, many employees are looking for ways AI can save time or eliminate undesirable tasks, while leaders are looking for opportunities to increase productivity.

AI is coming in hot and presents both risks and opportunities for well-being. Organizations should be looking for ways AI can improve both personal and professional well-being for employees—alleviating aspects of work that do the least for our well-being and augmenting aspects where humans thrive.

Flexibility still in flux

Finding the right flexibility approach is key. Multiple surveys conducted in the last six months indicate return to office results have been mixed. Many leaders have not seen the hoped-for productivity gains and many have lost more employees than expected in the transition. Flexibility is not a one-size-fits all solution, regardless of industry, size, location, or workforce demographics. The best flexibility models will balance performance management with a culture that promotes belonging, development, and trust. To find that balance, organizations will be well-served to take the time to evaluate the needs of their workforce, the needs of their business, and their capability to withstand, support, and manage different flexibility models.

Recalibrating physical wellness

While employers have limited control over personal well-being behaviors (and rightly so), there are steps organizations can take to set up employees for positive health outcomes. Free or low-cost healthy food, yoga classes, on-site fitness centers, and gym membership reimbursements are all fantastic benefits that will resonate with many employees and will also help set a tone that your organization values health. However, think of these as added perks. Most employees want to make healthier choices. It is not the organization’s responsibility or prerogative to convince them to be healthier, but an organization can take steps to make the healthiest choice the easiest and/or most affordable choice. The best way for an organization to support physical well-being is to remove barriers.

While it may be unrealistic to address all seven topics for your workforce, the key to being successful in 2024 is to take a holistic approach to well-being in the workplace. Leaders who recognize well-being’s broad impact and connection to other initiatives, and employ a strategic approach that considers how culture, programs, resources, and benefits work together, will be best positioned in creating a thriving workforce.

Download the full report, including key takeaways and best practice examples.

About BerryDunn's well-being consulting practice

BerryDunn partners with organizations to create work environments where business success and personal growth coexist, and where people are confident knowing their workplace positively contributes to their physical, mental, financial, and social well-being. We take a detailed approach to well-being, considering the whole person and the work environment to design well-being programs that are inclusive, equitable, and integrated into the way people work. Learn more about our well-being team and services. 

With the rapid growth of Medicare Advantage (MA) plans in the last several years, many hospitals are struggling to effectively manage the financial and operational challenges of these plans, including:

• Increased denials of Medicare Advantage claims
• Confusion between Medicare, supplemental Medicare plans, and Medicare Advantage (Part C) plans, and what each cover
• Extra burden of “shadow billing” inpatient claims and leaving potential reimbursement off the table if not done correctly
• Compliance risk, including the risk for Medicare fraud

This year, over 30 million people—more than half of those eligible for Medicare—have an MA plan. Medicare Advantage plans are inherently more complex than traditional Medicare, and many hospitals simply don’t have the appropriate processes in place to manage their nuances. However, by implementing the best practices outlined below, hospitals can decrease their Medicare Advantage risks.

1. Optimize your Electronic Health Record (EHR) to decrease Medicare Advantage denials

As with any insurance, you should understand the patient’s covered benefits well before they walk in the door. Collecting correct information at the time of scheduling is essential. In addition, for non-scheduled encounters, it is also essential to gather the correct information so that you can get the "prior auth" after the fact but within the specified time frame. Educating your patient access staff is essential. This is true for all plans, but since Medicare Advantage is often confused with traditional Medicare (by patients and providers alike), it’s even more important.

Most hospitals and provider groups leverage an eligibility and benefits tool that verifies coverage. These tools are often fully integrated into the EHR system. Revenue cycle leaders must ensure these tools are configured correctly and staff understand how to interpret the results. For example, running eligibility on a patient with Medicare will return an active result regardless of whether they have a Medicare Advantage plan or not. Patients must be eligible for Medicare in order to have a Part C plan. Most of the query responses do contain the additional information that the patient has a Part C plan and many EHRs can alert the user regarding this information.

BerryDunn recommends:

• Ensuring that staff members understand how the benefit verification vendor and EHR handle responses from traditional Medicare when the patient has an Advantage Plan
• Optimizing your EHR and workflow to manage these exceptions
• Training patient access staff around understanding responses and appropriate workflow

• Developing accompanying standard operating procedures and quick reference guides

2. Avoid authorization-related denials from Medicare Advantage

Authorization-related denials are a significant concern with Medicare Advantage. Two issues collide to form the perfect storm: Traditional Medicare does not require authorizations, and Medicare Advantage plans typically have stringent authorization requirements. The following is an example of a revenue cycle pain point that we see far too often:

The patient schedules an appointment and states that they are “on Medicare,” so they are registered with traditional Medicare. The patient needs an expensive procedure, and following Medicare rules, the staff believes no authorization is required. Approximately three weeks after the procedure, the hospital receives a denial stating the patient has a Medicare Replacement Plan. The accounts receivable staff member then bills the replacement plan, and now 60 days or so after the procedure, a second denial is received for no authorization. The claim will now get sent back to patient access and “ping-pong” around the revenue cycle. The ultimate result is most likely a write-off as most Medicare Advantage plans do not allow for retroactive authorizations after this much time has passed.

The revenue loss due to the volume of this type of scenario can be staggering, but with tools and training, it can be nearly 100% avoidable!

On a related note, there is a new bill being introduced in the US Senate, the Requiring Enhanced and Accurate Lists of (REAL) Health Providers Act, that is looking to ensure MA plans maintain accurate provider directories. This could be another tool that the frontline staff uses to identify traditional Medicare participants from MA plan participants. Asking “How did you find us today?” for new patients may solicit additional helpful information.

3. Don't neglect "shadow billing" of inpatient claims for MA beneficiaries

On top of the administrative burden of contending with prior authorizations and satisfying the billing requirements of the Medicare Advantage plan, hospitals, swing bed units, and skilled nursing facilities are also required to submit no-pay claims to the Medicare Administrative Contractor (MAC) for inpatient services provided to MA patients. This type of duplicate billing is often referred to as “shadow billing” since claims are submitted to both the MA plan for payment and MAC as information-only billing. It’s not uncommon for these shadow claims to be overlooked, or not billed to the MAC properly, which results in potential revenue loss or compliance risk related to:

• Reimbursement for Medicare’s share of indirect graduate medical education or nursing/allied health education costs. MA plans do not make payments for medical education costs, but the Medicare program will pay teaching hospitals directly for it based on the number of MA patients they serve as determined by shadow claim billing and reimbursed via the annual cost report settlement.
• Hospitals that are eligible for Disproportionate Share (DSH) payments receive additional operating and capital payments intended to offset the financial burden of treating a disproportionate share of certain low-income patients. It’s important that MA inpatient days are reported through shadow claims to properly capture days in the SSI percentage used to determine these payments and optimize reimbursement via the annual cost report settlement for DSH.
• Skilled nursing facilities and swing-bed units must submit shadow claims for beneficiaries enrolled in MA plans and receiving skilled care in order to take benefit days from the beneficiary and/or update the beneficiary’s spell of illness in Medicare’s common working file (CWF).

BerryDunn recommends that you periodically review your shadow billing processes to ensure that you’re capturing all Medicare Advantage inpatient claims and not leaving any potential reimbursement off the table.

4. Stay on top of best practices for Critical Access Hospitals receiving Medicare cost-based reimbursement

For Critical Access Hospitals (CAHs) that receive cost-based reimbursement from Medicare, there’s an additional layer of revenue risk related to the proliferation of MA plans. MA plans typically pay CAHs' based on a factor of their Medicare rates, which are based on the CAHs allowable costs. However, unlike traditional Medicare, MA plans do not retroactively settle payments based on actual allowable costs from its annual cost report filing. This means that a CAH is not actually paid its allowable cost to treat all Medicare beneficiaries, only those that are enrolled in traditional Medicare, which is a shrinking population. The Medicare Cost Coverage Ratio (the proportion of allowable costs that are reimbursed by Medicare) for CAHs throughout the United States shrunk by nearly 15% from 2018 to 2022 and is expected to continue to shrink as participation in MA plans grows. This puts a CAH’s cost-based reimbursement at risk.

A CAH may be underpaid or overpaid by an MA plan throughout the year if its interim Medicare rates are not close to its actual allowable costs. BerryDunn recommends that CAHs take the following steps to mitigate revenue loss and receive payments from MA plans that are reasonably close to their actual allowable costs.

• Regularly estimate Medicare cost report settlements (ideally every month, but at least quarterly). If necessary to incorporate operational changes, prepare an interim cost report to provide a more accurate estimate.
• Establish a threshold for your settlement estimate that would trigger you to request an interim rate adjustment.
• Send Medicare rate letters to all MA plans as soon as possible after you receive them so the MA plan can update their payment rates.
• If you’ve made significant investments or operational changes that would have an impact on your costs, don’t wait for your annual cost report filing to see the impact. Consider submitting an interim rate review to incorporate these changes into your Medicare and MA rates in a more timely fashion.

5. Understand your obligations at the time of contracting and enrollment  

As mentioned above, many of the MA products are included as part of a commercial contract. While not inherently "bad," it is important that each provider organization is clear about the differences in plan administration (authorizations, formularies, panel closure notifications) that may cause workflow changes for the staff to ensure revenue integrity and the rates. Typically, a small percentage of MA plans are reimbursed on "Medicare Plus." However, this percentage varies greatly, as do the payer policies. Several MA plans are introducing value-based programs. It is very important for each organization to understand the obligations clearly before engaging in these programs.

While the MA plans may look like they are part of the commercial agreements, the enrollment process for these plans is reliant on the completion of the traditional Medicare enrollment. Far too many times, we have seen providers forget to go back to the commercial plan to ensure that the provider has been linked to all of the products, again resulting in denials.

From labor shortages to regulatory changes, today’s healthcare organizations face greater challenges than ever. BerryDunn's audit, tax, clinical, and consulting professionals, focused on specific healthcare industry areas, understand these challenges, and are committed to helping you meet and exceed regulatory requirements, maximize your revenue, minimize your risk, improve your operations—and most importantly—facilitate positive outcomes. Learn more about our healthcare consulting team. 

Nearly every type of business relies on external service providers to help keep operations running smoothly and to provide customers, clients, or patients with high-quality service and care. Whether it’s a cloud-based accounting or HR system, an outsourced medical billing provider, a financial services core system, or an investment management application, service providers can make your job easier and more efficient. But remember: You can outsource operational functions, but you cannot outsource responsibility.

Effective oversight of service provider vendors is essential for managing risk and potential adverse impacts to your reputation. For instance, patients don’t care that it was a third-party who didn’t patch a server that gave hackers access to their personal data; they care their data was exposed and they hold you, as the service provider, responsible for lack of oversight of your contracted third party (sub-service organization). Unlike functions that are performed in-house, when services are outsourced, you may have limited information on hand and less control over the process. A System and Organizational Controls (SOC) report can be an invaluable tool in helping you gain confidence about the controls at your service providers.

What is a SOC report?

A SOC report is a way to verify that an organization has designed sufficient controls and that those controls are in place and operating effectively. These controls are typically related to organization and management, operations, logical security, networking, access, application processing, privacy, and availability. These controls are tested for operating effectiveness by independent third-party auditors. Any exceptions are identified in the SOC report and may vary by severity from a report qualification to a minor issue. Based on the type of SOC report (explained below), it is up to you as a service organization to determine the impact on your business and customers of any noted exceptions and to act accordingly.

Which SOC report should you request?

There are primarily two different types of SOC reports. It is important to understand these types so that your organization can obtain the most relevant report to address your reporting and vendor due diligence needs. You may also have a need to require both reports from a service provider, which is very common.

• SOC 1: Reports on controls at a service organization that may be relevant to user entities’ internal control over financial reporting. These would be ideal for organizations whose service organization provides a service that would impact financial reporting (ask yourself: Is the service provided impactful to your financial statements?)
  • Type 1: A design of controls report. This option evaluates and reports on the design of controls put into operation at a point in time. You can think of this as a “kicking the tires” report.
  • Type 2: Includes the design and testing of controls to report on the operational effectiveness of controls over a period of time. This is more of a “deep dive” report.
• SOC 2: The purpose is to evaluate an organization’s information systems relevant to security, availability, processing integrity, confidentiality, or privacy. The SOC 2 has predefined criteria in which the service organization identifies internal controls they need to address the criteria. A SOC 2 audit is more prescriptive than a SOC 1.

It is not uncommon for service organizations, especially larger ones, to have many SOC reports covering many specific functions and systems. They may also have a SOC 1 and SOC 2 report for the same function or system. A SOC 1, Type 2 report is more valuable than a SOC 1, Type 1 report since it tests the operational effectiveness of controls over a period of time. A financial statement auditor will likely want to see a SOC 1, Type 2 report. Type 1 reports are typically done the first time a service organization undergoes a SOC exam, with the expectation that in subsequent years, a Type 2 report will be issued.

When should you request a SOC report?

Not all service providers need to be treated equally from a monitoring perspective. Perform a periodic risk assessment to determine how risky a service provider is to your organization. This risk assessment should consider items such as:

• What functions are they providing to your organization?
• Is the service organization’s service material to your financial statements?
• Does the service organization have access to your systems and data?
• Does the service organization have access to, process, manage, and maintain customer personally identifiable information (PII) or credit card information?
• Have there been issues with this vendor in the past, including through review of their SOC report?

This risk assessment will drive the level of monitoring needed on an ongoing basis, including if review of a SOC report is necessary, and the frequency of this review.

How to conduct and document a SOC report review

For those service providers in which SOC reports will be reviewed, make sure you have a consistent review process that is followed each time. BerryDunn has a review checklist available on our website to ensure your review is consistent and captures the salient items. 

When you receive a SOC report, it should be thoroughly reviewed and documented, including the date of the review and who performed it. More so than reviewing the SOC report, you must also review user control considerations (UCCs). UCCs are controls that the service organization had included in the report as critical to the internal control cycle and are the responsibility of you, as their customer. The UCCs should be reviewed and determined if they are applicable to the services you receive from the service organization, and if they are, you should determine that controls are in place and should be tested internally for operating effectiveness.

There are certain items within a SOC report we recommend that you review and document:

• System or function covered: Make sure the SOC report covers the function or system pertinent to your organization.
• Type of report: Is it a SOC 1 or SOC 2? If a SOC 1, is it a Type 1 or Type 2?
• Period covered in the report: What period does the report cover? If being used for a financial statement audit, is a bridge letter needed?
• Service auditor: Who is the service auditor? Are they reputable, qualified, and independent from the service provider?
• Opinion: Review the service auditor’s report. What opinion was provided? Were there any opinion exceptions?
• Subservice organizations: Does the service provider rely on any third-party service providers?
• Control objectives: Review the controls pertinent to your organization. Were there any testing exceptions identified?

The use of service providers, for most organizations, is unavoidable. It is important to have a thorough process to monitor these service providers to help ensure they don’t adversely impact your organization’s operations. Requesting and reviewing SOC reports from your service providers is one effective due diligence mechanism. We hope you will find our SOC review checklist helpful and, to learn more, please watch our video on how to effectively use this checklist.

Healthcare system conversions are risky endeavors. But what is the alternative? Stay with a system you’ve outgrown and no longer meets your organizational needs? At BerryDunn, our healthcare consulting teams have worked with a substantial number of organizations as they’ve transitioned to new enterprise systems such as Electronic Health Records (EHR) systems and Enterprise Resource Planning (ERP) systems. Based on our experience, there are 10 key areas to focus on in order to have a successful conversion.   

1. Start preparing early 

If you know you’ll be bringing in a success partner like BerryDunn to help you through the conversion, bring them early in the planning as possible. The success of the entire project depends on how well you’ve planned and if you've brought in a strong methodology to approach the implementation.   

2. Assess your needs before you make a decision to change systems 

Before you even decide that you need a new EHR or ERP system, the first step is to conduct a thorough assessment of your current system and determine if you actually need a new system.  It’s possible that your current system could and will meet your needs if set up correctly.  

If you determine that you do need a new system, the next step is to conduct a thorough needs assessment that details exactly what your organization needs out of the system. It’s important not to think in terms of what your old system was capable of, but to focus on the problems that you want the new system to solve. Talking to other organizations or consultants like BerryDunn, who are solely focused on and have experience in this work, can help you determine what best-in-class systems can do.  

3. Understand and mitigate the risks 

There are risks at every stage of the process, from not identifying your needs correctly, not assessing the facility’s readiness for change, choosing a subpar vendor, having an incomplete contract, not monitoring the implementation very closely to meet the deadlines, and not addressing the risks as they appear. It’s important to manage the steps correctly at each phase, beginning with: 

• Documenting detailed requirements for the EHR or ERP system 
• Initiating a formal RFP process to include the system requirements in writing 
• Thoroughly vetting and evaluating vendors consistently 
• Negotiating a solid contract that holds the vendor accountable for support and a timeline 
• Assessing what staffing changes and training are needed 
• Providing sufficient time for testing pre- and post-go-live 
• Understanding and planning for the impacts to your revenue cycle 

4. Manage the vendor 

The vendor may be managing the project, but who is managing the vendor? Whether you hire a consultant like BerryDunn or have in-house resources, managing the vendor can be a full-time job. In our experience, the vendor wants to have a successful implementation as much as you do, and they also want to go live on time so they can move on to their next project. You will need to advocate for your organization and be able to hold the vendor accountable to what was agreed on, even if that means taking more time. If your contract was thorough, you should have enough leverage to do so. The bottom line: Don’t feel rushed to go live until you know you are ready. 

Insist on a detailed implementation plan from the vendor that shows realistic timelines for the tasks needed to be accomplished to meet the go-live date. The project should include weekly communication meetings with the vendor to ensure any problems and delays identified can be addressed quickly. 

5. Make sure your internal project team is ready 

Just as it’s important to ensure your vendor is well-staffed, prepared, and held accountable, these factors are equally important for your internal project team. Take the time at the beginning of the project to create a plan for success that takes into account roles, communication, and contingency plans. A good plan will include:  

• Establishing a project charter to formalize governance, teams, and roles and responsibilities 
• Communicating and reinforcing the project as a mission-critical effort 
• Establishing regular project meetings to follow up on and manage risks, actions, issues, and decisions 
• Monitoring competing priorities and alleviating non-project efforts for staff where possible  
• Anticipating project team turnover and having a plan for backfilling team members in advance 

6. Help your staff adopt the new system 

Even if you implement the best system in the world, if your nurses, doctors, and billing staff don’t use it (or don’t use it correctly), it won’t be effective. You need to be able to manage the people side of change, starting with building the case for why you are switching systems and how it will benefit the working staff. Having a thorough training plan and making sure people are ready for the conversion is a key step that shouldn’t be neglected. 

7. Allocate enough time and the right resources for testing 

Before you go live, you need to know the system is going to work for specific scenarios in every department that uses it. For EHR systems, that is every department that touches a patient. A solid testing plan begins with identifying the key, critical scenarios in each area and assigning the right people to be involved in testing – ideally, those who will be using the new system and have a firm grasp on the typical workflows. The plan should “follow” a patient from the point of registration to treatment, discharge, billing, and patient follow-up. A good testing plan will confirm if the system functions as intended and will drive issue resolution and any needed configuration changes. Ultimately, the result of testing will be to determine if you’re ready for go-live.  

8. Get your accounting systems in order  

Many healthcare organizations implement new accounting ERP systems at the same time they convert their EHR. It is important to determine concurrently how the operational and financial data from the EHR will be integrated into the general ledger and reporting dashboards. A study will need to be made on the ease with which the payroll information from the outside software application can be accurately uploaded. Your chart of accounts likely will need to be revamped.  Electronic invoice routing and approvals have become very sophisticated and can improve efficiency with the proper setups. Your new accounting ERP system should not be a “last minute thought” but carefully selected and planned as the EHR is being implemented to ensure accurate and state-of-the-art reporting to deliver to your internal and external audiences.   

9. Don’t neglect your revenue cycle 

Launching a new system is not business as usual. Most new EHRs introduce new complexity to the clinically driven revenue cycle. This requires different management skills and tighter coordination across the organization. Success requires advance planning around charge master structure changes, patient access, and other workflows that will heavily change. Attention needs to be paid to leveraging clearinghouse functionality, and testing plans should incorporate all charging and payor scenarios.  

In addition, no matter how prepared you thought you were, your clinicians are just not going to be able to do things as fast as usual when using a new tool. It takes time to build proficiency in any new system. When launching a new EHR, you’ll need to schedule lighter patient loads in the weeks after your go-live, allowing flexibility for fixing problems and for taking into account learning curves.  

Because of this lighter load, your revenue cycle will be impacted. Fewer patients will be cared for, and fewer patients will be billed. You need to consider these cash flow impacts and plan around legacy receivables well before launch day (ideally as much as two years prior) so you can plan for it and ensure that you’re accounting for, and finding ways around, any shortfalls.  

10. Manage the post-go-live transition 

So you went live with your new system. Congratulations! But this isn’t the end. The two weeks after your go-live date are very important. Are you meeting with the vendor to track defects? Are you getting everything out of the system that you dreamed of? Do you have a plan for addressing deficiencies and adding more functionality? Most vendors have a two-week window to help you post-go-live. You need to take advantage of that while you still have their attention. Once you transition to help desk support, you’re just not going to get the attention that you were before. Having a plan and a system in place for these post-go-live weeks is crucial.  

Is it time to bring in a success partner?  

To be successful, you need a partner who can address all of your needs and be your advocate, and expert, providing the support – and the answers – to questions you might not even know to ask. BerryDunn’s Healthcare team works with healthcare organizations every day, all year long, guiding them through EHR and ERP selection, vendor management, system implementation, testing, and beyond to mitigate risks and help ensure your investment pays off. We’re happy to discuss how we can help you with project and change management, interim or project staffing assistance, system report creation and dashboarding, and revenue cycle optimization. Contact a member of our team.