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CMS Manuals for SNFs

You strive to maintain and grow your reputation as a quality provider of care for long term and subacute care.  But you also monitor and control your costs.  But you may need help in conducting a more in depth analysis and corrective action in the area of overtime hours in the nursing department. 

The use of an outside consultant to work with your leaders in finance and nursing to review the utilization of overtime by the nursing department, identify patterns, trends, and causative factors, develop and facilitate process improvements, and monitor their implementation helps you to focus attention on this important area quickly.  By working through the process with your leaders and staff, and building on their experience and skills, they will be more likely to internalize these new skills and maintain the focus without the need for outside assistance.
I provide these consulting services across the county.  For more information, please fill out and send me the information on the form below: 

If your health care facility’s managed care contracts are up for renewal, here are a few tips on what to look for.  Prior to showing up at the negotiating table, your facility should be prepared.  Have a good idea of what the “low end” of the levels of care is that you will accept.  This would require that prior to negotiation you should know what your variable and fixed costs are at the time.  Know what it costs, both in direct and indirect variables, for you to provide care to each level of managed care patient. Be prepared with statistical data to make your case.  If you are achieving great clinical outcomes for their members, prove it to the Managed Care provider. You need to brag about it. For example, you may want to point out to them that you rehabilitate and discharge their patients after hip replacements in 14 days, while the average is 22 days.  Of course you must be armed with ammunition.  Be prepared to provide proof of this claim.  Have the list of patients (no names, coded) with the length of stay of stay to back your claim.

Negotiating the highest rate is not the only goal of the negotiations.  You must consider the operational impacts of the deals you make.  For example most would agree that negotiating exclusions limits financial risks. This is true in theory.  In practice it could be different. Billing and follow up for exclusions requires a lot of time and resources.  The cost savings of carving out the exclusions needs to be evaluated with the operational issues and the cost of billing them separately.  And be careful not to negotiate such a good deal for your facility, that you cost yourself out of referrals from the managed care company because you are too successful.  A good negotiation results in good value to both parties—the facility should get a fair rate, and the managed care company should get a quality and efficient program that is value priced.

 CONTRACT RENWAL CHECK LIST

1.     Does the contract contain an automatic renewal clause?

2.     Does the contract contain an inflation index?

3.     What services are excluded?

4.     How should exclusions be billed? In one bill with the Room and Board? Separately?  What billing form? Electronically? 5.     Is the termination notification for no more than 90 days (with 90 days being the best practice)?

6.     What are the provider’s obligations to continue, and the payer’s obligations to pay for, care for patients in treatment at the expiration of the contract?

7.     Does the facility have the ability to obtain member deposits for non-covered services?

8.     Is there an exclusivity clause?

9.     Are subcontracting relationships disclosed?

10. Is “medical necessity” clearly defined? What are the criteria for medical necessity?

11. Is there a definition of “covered services,” and are covered services clearly defined?

12. Is the plan agreement clearly defined?

13. Is “material breach” clearly defined and do terms include the plan’s failure to adhere to reporting obligations?

15. How many days of advance notice to providers is required for modifications in payments, covered services, procedures, documents, and requirements with “substantial impact”?