May 15, 2024 • 27 mins
Whether you are an agency owner looking to enhance your financial operations or an administrator curious about how your team can better manage the fiscal realities of the home care sector, this episode is a masterclass in navigating the shifting landscapes of health care finance. Learn about navigating the complexities of Medicaid disenrollments and electronic visit verification (EVV) as Alik Kassner, co-managing partner of Alpine Homecare, provides insight into improving revenue cycle management (RCM) practices. With Alik's impressive banking and health care background, he discusses formidable obstacles, the essential role of forecasting, and how state assistance and advanced technology merge to create a robust RCM system.
If you liked this episode and want to learn more about all things home-based care, you can explore all our episodes at alayacare.com/homehealth360.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Alik Kassner (00:00):
We were probably one of the first ones to
recognize that, hey, some thingsare going horribly wrong here,
because we saw, as I said, everyfirst of the month, 10, 20, 30
clients getting disenrolled.
Now this is where my reallywide definition of revenue cycle
management kicks in.
(00:20):
This is what I would say.
Processes and people are soimportant, in addition to a good
IT system that helps you trackit all.
We basically introduced adedicated team that started
working with our clients to tryand see why they were getting
disenrolled and what we could doto prevent that from happening.
Erin Vallier (00:52):
Welcome to another episode of the HomeHealth360
podcast, where we speak tohome-based professionals from
around the globe.
I'm your host, Erin Valliere,and today I am joined by Alik
Kassner to talk about bestpractices in revenue cycle
management.
Alik is a co-managing partnerat one of Denver's largest
(01:14):
non-medical family-owned homecare companies.
He holds a master's degree inbusiness from the University of
Toronto and, following a 20-yearcareer in banking, he has been
working in healthcare as anexecutive in Denver since 2012.
Alik is an active member of theHome Care Association, Home
(01:35):
Care and Hospice Association ofColorado, or HHAC.
He's been working on theLegislative and Regulatory
Committee and is activelyinvolved in HHAC's response to
new legislative and regulatorychallenges, as well as being the
association's point person forEVV.
Welcome to the show, Alik.
Alik Kassner (01:57):
Thank you for having me.
Erin Vallier (02:00):
I think you have the relevant background and
success in revenue cyclemanagement to talk about all
things best practices to setpeople up for success.
So let's dive in, let's.
What does revenue cyclemanagement, or RCM, mean in the
context of a home care agency?
Alik Kassner (02:21):
Well, RCM can mean many different things to many
different people.
I can tell you what it means tous here at Alpine.
To us, it's basically the grandtotal of all activities dealing
with the revenue cycle,starting from the structure and
the process, for example, thestructure and the process, for
(02:42):
example, your billing frequency,as opposed to when you are
doing payroll and paying outpayroll.
It covers what are your inputsinto your billing process paper
timesheet, electronic timesheets, what are you using to collect
those?
And obviously also it coversall the IT side, the IT systems
(03:05):
connected to it.
What do you use?
How easy is it to generate abatch billing file that you can
then put into the payer andhopefully get paid at some point
?
And even further, it's not justhow easy or difficult is it to
generate that file for you andyour billing team, but also
(03:25):
afterwards, how easy is it totrack?
Can you, for example, upload anelectronic remittance and then
see where you got paid and whereyou didn't get paid?
And what tools do you have tobasically then track where you
didn't get paid and how easy isit for you to then resubmit
those claims where you didn'tget paid and how easy is it for
(03:45):
you to then resubmit thoseclaims where you didn't get paid
.
That's in a nutshell, I think,what we understand by that, in
our shop at least, Gotcha.
Erin Vallier (03:55):
So it's this big mixture of people, technology
and processes to make sure thatyou get paid, and that can be
incredibly complex at times,which I'm sure we're going to
talk about.
How crucial is effective RCM inthe success of a home care
business?
Alik Kassner (04:12):
Imagine you operate, like we do, in a
relatively thin margin businessright.
Your prices, your Medicaidrates are dictated to you.
Your costs are dictated to youvia caregiver base wages and
other things, and in between iswhere you have to make a living.
And if your processes are notset up correctly, if you
(04:35):
experience unexpected revenueshortfalls and you cannot manage
that properly, you willliterally not make payroll.
And in our business you failyour payroll once.
That means your caregiversdidn't get paid.
Now imagine how motivated thosecaregivers will be to go to
your clients the next day andprovide services.
(04:56):
Probably not very so.
It is absolutely key to have asystem that works, that ensures
that you are a reliable partnerfor your caregivers and your
clients.
Erin Vallier (05:10):
Yeah, that makes sense to me.
If they don't get paid, they'renot going to show up, and the
caregivers are at the heart ofwhat you do.
Alik Kassner (05:16):
Of everything we do.
The caregivers are the mostimportant thing in everything
that we do, absolutely.
Erin Vallier (05:23):
So what are some of the common challenges that
home care agencies face with RCMand at a very high level?
How do you go about addressingthem?
Alik Kassner (05:31):
So I think Alpine has been around now for close to
a quarter of a century and overthat time span I've been there
for now 12 years, so not quitethe entire time, but since I've
been there the events impactingyour revenue have just
quadrupled or quintupled.
(05:52):
There's so much more, so manymore reasons nowadays why your
claims could get rejected.
We've seen the introduction ofelectronic visit verification.
We've seen the introduction ofelectronic visit verification
(06:17):
and once they turn on the claimsedit, which means if something
is missing in your things, youknow that immediately impacts
your revenue cycle, immediatelyimpacts claims.
You won't get paid.
And then there's various otherissues in terms of client
eligibility and PARs that Ithink we can get in a little bit
(06:40):
later.
The grand total of all theseissues that could potentially
impact your claim, that havegotten so much larger over time,
just forces you to have asystem that allows you to
monitor whenever you not getpaid and to then also track and
resubmit these claims.
That's become a lot morecrucial because the instances
(07:04):
where you don't get paid havebecome so much more prevalent
than in the past.
Erin Vallier (07:10):
So a lot of stuff is happening on the regulatory
side that is making it harderfor you to get paid for the hard
work that you do.
I'm sure we're going to getmore into how you can combat
this.
I think what you're hinting ator at least one of them is
something you shared with mewhen we were talking to prepare
(07:31):
for this conversation is theMedicaid disenrollment that
happened when the pandemic ended.
It makes sense, right?
So a lot of people went onMedicaid when they lost their
jobs from the pandemic and sowhen the pandemic was over, it
makes total sense that thosepeople would lose their
enrollment because they got ajob and they're doing all right.
(07:53):
But I heard and I'm sure you cangive me some more intimate
details that there was a majoradministrative boo-boo, if you
will, on the state level thatjust disenrolled a bunch of
people that should not have beendisenrolled.
And I looked into it a littlebit and I think in the state of
(08:14):
Colorado it varied across states, like 8% in Wyoming were
disenrolled up to 82% in Texas.
So there's like all over theboard what happened state by
state.
But in Colorado I couldn't finda hard and fast number, but
somewhere between 42 and 56% ofMedicaid recipients were
disenrolled and two thirds ofthose that lost their coverage
(08:39):
because of an administrativeerror.
How did that impact you and howdid you deal with that?
Because I think this would be aperfect case study in revenue
cycle management.
Alik Kassner (08:51):
Yeah, let's talk about what's going on and is
going on in Colorado.
In Colorado we actually, Ithink we had the perfect storm.
So number one, and certainlythe biggest, is what you've
mentioned the Medicaidredeterminations.
After not having to redetermineMedicaid clients during the
pandemic last summer, the annualredeterminations resumed.
(09:16):
To a lack of staffing on thecounty level, the financial part
of the Medicaid redeterminationdid not happen and many
counties were backlogged and arestill backlogged to this day.
The effect of this is that, asa Medicaid client, even if you
(09:40):
did receive your redeterminationpackage in the mail and let's
be clear, not all people did,but let's say you did and even
if you collected all thedocuments that are necessary
your bank accounts, variousstate plans, utility bills and
so on and so forth and even ifyou submitted all that on time,
(10:01):
whether it's electronically orvia snail mail all that landed
at your county and that's whereit stayed, without anybody
looking at it, for an extendedperiod of time, while your
redetermination period came andwent, and then you were
automatically disembroke.
So that is what happened to agreat number of people and
(10:26):
that's one of the problems thatColorado was facing.
But on top of that, there's twoother things that were going on
.
So also last summer, hicpapHealthcare Policy and Financing
essentially the state ofColorado saying essentially the
(10:47):
state of Colorado, theregulatory authority introduced
a new care and case managementsystem and despite a lot of
testing, that system did notwork as advertised.
So a lot of case managers thatare responsible for the
functional determination justthe other piece in terms of you
need a functional assessment andyou need a financial
(11:08):
eligibility and both togetherthen you can get approved for
your Medicaid services butbecause of CCM not properly
working, they had a verydifficult time doing their job
and we got an email from a casemanagement agency basically
saying hey, we're very sorry,but we may not be able in all
(11:31):
cases to access client records.
Where we can't access clientrecords, we may not be able to
issue a PAR, we may not be ableto change a PAR, we may not be
able to print our power.
We may not be able to print.
Stuff is just a nightmare and Ithink there were 28 known
errors with the system and 42workarounds, and so processes
(11:55):
that under the old system took acase manager of 10 minutes now
took half an hour or longer.
So a really big problem on thatside.
That obviously doesn't helpwith the Medicaid
redeterminations.
And then the third part of theperfect storm was case
management redesign, which is afederal mandate that was getting
(12:17):
implemented here at least thefirst stage in Colorado,
starting November of 2023.
We're mainly a Metro Denverprovider, so I'm just going to
speak for the Metro Denver area.
For Metro Denver, thatbasically means that all clients
in Arapahoe County were movedfrom one case management agency
(12:38):
Rocky Mountain Human Services toanother, to developmental
pathways, and all clients inAdams County were moved from
North Metro to Rocky MountainHuman Services.
The takeaway from this isthousands of Medicaid clients
were moved from one agency toanother with a system CCM care
(13:00):
and case management that is notfully working, on top of which
some of the very same clientswere being automatically
disenrolled because of thebacklog on the county level.
I think this sort of perfectstorm, as I describe it, is, in
a way, a perfect advertisementfor why you need a good revenue
cycle management system.
(13:20):
You need a good revenue cyclemanagement system Because, as a
provider, each first of themonth, we were all faced with a
significant amount of clients.
How significant depends on yoursize, but for us it was 10, 20,
(13:41):
30 clients each first of themonth where you see they're
getting a discontinue in thesystem.
You know and all theregulations say hey, before you
start providing service orcontinue to provide services,
check eligibility and if youlook at eligibility in that
system for those clients, ittells you they're disenrolled.
You are supposed to sellservices.
(14:01):
Now, we are not heartless humanbeings and we at Alpine did
generally not stop services.
But if you're a small provider,do you have a choice?
Because if you do not stopservices, that means you keep
sending your caregiver.
That means you have to keeppaying your caregivers without
(14:24):
you being paid your caregiver.
That means you have to keeppaying your caregivers without
you being paid in return.
So a lot of providers could notdo that.
The reason why Alpine was ableto do it is we were first of all
.
We were like probably one ofthe first ones to recognize that
, hey, some things are goinghorribly wrong here, because we
(14:45):
saw, as I said, every first ofthe month, 10, 20, 30 clients
getting disenrolled.
Now this is where my reallywide definition of revenue cycle
management kicks in.
This is what I would say.
Processes and people are soimportant, in addition to a good
IT system that helps you trackit all.
(15:06):
We basically introduced adedicated team that started
working with our clients to tryand see why they were getting
disenrolled and what we could doto prevent that from happening.
And it turned out pretty quicklythat in most cases the reason
they were getting disenrolled istheir paperwork was at the
(15:27):
county level but nobody waslooking at it.
So we started filing HCPFescalation forms, which at least
initially forced somebody inthe county to look at what was
going on.
They need to pick up the fileand see oh, this is the file for
client XYZ.
There's actually everythinghere I need to complete the
(15:48):
redetermination successfully.
So I'm just going to do thatnow and boom, you got a client
coming back into your revenuecycle because their Medicaid had
just been restored.
It's not quite as easy as I say, because once the Medicaid got
restored they still need to goand have the case management
agency issue the PAR.
(16:09):
So this is where the CCM systemI mentioned earlier was not
very helpful, because sometimesthey couldn't access the info,
they couldn't issue the PAR dueto technical issues and other
things.
But this was helping us gettingclients back.
The other thing that we didthat our team did was we started
(16:32):
filing appeals with the Officeof Administrative Courts, which
sounds really scary becauseyou're going to court to get
your Medicaid back.
But we did that on behalf of ourclients and once again our
experience there was thatprobably around 85% to maybe
even 90% of these appeals thatwe filed got resolved without a
(16:58):
hearing, without a court hearing, and about 10% we and the
client attended these courtappearances.
Thankfully they were virtual,so it's like you had to go to
the courthouse of the client.
He could be on Zoom and helpthe client get on, and I think
we still have 100% success ratioin these appeals.
Yeah, in part because, again,this is not the fault of the
(17:23):
client.
The client had submittedeverything, like the cases where
there's something missing orthe client had forgotten to
submit something or the case youdescribed in the beginning,
somebody who lost their job andthen, after the pandemic, they
resumed their job, they got itback and now they earn too much
to make.
Medicaid virtually didn't existin our world.
(17:44):
Our clients are all elderlypeople.
They're all on the elderly,disabled and blind waiver most
of them, and nothing changed.
They didn't win the lotterysince the pandemic.
So all our cases were reallyclear.
What basically ended uphappening was back now.
(18:06):
We filed over 160 appeals andover 80 Hickapuff escalation
forms, and this is a processthat was ongoing basically since
last fall and where it then allkind of ties together is each
(18:35):
month.
Not only did we see, oh, we'relosing another 30 clients and
how we're going to make payroll,but we also saw 10, 20 clients
coming back good enough to trackmultiple.
We literally had to submit someclaims, probably 10 to 15 times
, and we were able to track allthat, and not only track what we
needed to resubmit and what wegot paid and the clients that
(18:57):
were coming back as opposed tothe ones that're losing, but we
were also able to relativelyaccurately forecast, okay, what
are we going to get paid in thisnext cycle, as opposed to what
our payroll was going to be.
And, long story short, all ofthis combined allowed us to not
(19:20):
having to suspend services toour clients.
That's a really big dealbecause we look around and a lot
of people had to suspendservices.
We understand those reasonsvery well.
They were threatening us aswell, but because of our
approach we were able tocontinue and there was help from
(19:40):
HICPA, from the state.
You could take out a loan, butyou know very well a loan
doesn't really help you if,number one, you have to pay it
back.
Number two, if it doesn't breakthe trend that every month you
lose many more clients, theireligibility goes away but you
can't get them back and youdon't have enough money to make
payroll, other than maybe fromthe loan.
(20:02):
But that's going to run outeventually and the state is
going to take it back out of therevenue that you're supposed to
generate In our view thatwasn't really a solution or not
the optimal solution, and wefelt very vindicated when
finally the state in March Aprilso a month, only a month or two
(20:23):
ago finally figured out okay,we really need to do something,
and started with automaticextensions of Medicaid,
redeterminations and eligibility, automatic PAR extensions, and
they also did some automaticreprocessing mass reprocessing
of previously submitted claims.
And I think they did it two orthree times since then and both
(20:48):
times we got tremendous amountof money back of unpaid claims,
to the extent that I think we'renow basically 95% all paid up.
And the most surprising thingfor us is when I talked to some
of my colleagues, they're likeno, we didn't really benefit
from that, we didn't really seean improvement, and the reason
(21:08):
why they didn't and we did isbecause they stopped services.
So if they stopped servicesthen of course they're not
getting reimbursed for anythingright now.
Erin Vallier (21:18):
I would agree you took a very expansive and
creative approach to it, and itwas risky too, because if you
provide services and they're notcovered, then you run a high
risk of never getting reimbursed.
So that took a little bit ofbravery there, and then some
creativity, to have a teamassembled who was just dedicated
(21:39):
to doing something that not alot of other agencies do,
because it's my understandingthat it's not very common to be
that hands-on with the client toget them redetermined and also
to do those appeals.
I don't think very many otherpeople go to that length, but
this is just definitely a greatcase study in what is possible
(22:02):
if you're willing to just rollup your sleeves and do something
a little bit outside the box.
I want to talk a little bitmore about technology, because
you've mentioned it a coupletimes.
How do you leverage technologyto streamline your RCM process?
Alik Kassner (22:16):
I think that's just that you need to have the
technology to support yourregular efforts, your team's
efforts.
If you cannot track what you'redoing with all these appeals
and redeterminations, if youcannot resubmit repeatedly and
easily once you've got Medicaidand the PAR restored, if you
(22:39):
can't track and if you can'tforecast the effects of it all,
then you're not going to be verysuccessful.
You're still flying blind.
You still won't know if youhave enough money to make
payroll.
So technology having a goodsystem, I think is very much key
in all of this.
Erin Vallier (22:57):
We'll submit for you, resubmit for you and then
track.
So let's talk about tracking.
What are some of the KPIs, orkey performance indicators, that
you use to track the financialhealth of your agency?
Alik Kassner (23:12):
We use a fair amount of indicators.
I'd like to think at least someof them are key.
But we basically monitor ourclients, the number of our
clients' hours, so service hours.
We obviously monitor veryclosely revenue and cost.
We obviously monitor intake.
(23:33):
We monitor sort of thepercentage of what we get paid
on.
We also have measures in termsof profitability by client,
although, to be honest, in theMedicaid world a lot of the
clients, the rates, are the same.
The only differential there isbasically usually the hours.
(23:56):
The caregivers make more orless the same plus minus a
dollar or two.
But yeah, you can track a lotof things.
I think for us the mostimportant ones are the ones I
mentioned.
Erin Vallier (24:10):
So what's coming in and what's going out, and it
better be in the green right.
Alik Kassner (24:14):
It better be in the green, but also the hours.
Are we increasing our hours?
Are we not increasing our hours?
And then we have a great dealof many different payer sources,
at least for an agency of oursize, and you have to be able to
obviously also administer andtrack those.
Erin Vallier (24:35):
We've covered a lot of stuff in our conversation
so far today.
I just have one final questionfor you, Based on your
experience what advice would youoffer other agency owners or
administrators who are lookingto improve their revenue cycle
management practices?
Alik Kassner (24:53):
Have a good system .
It sounds simple, right, butagain, if you just look back,
maybe five, even six years, noneof these problems existed.
You didn't have EVV, so yourclaims, if there was a PAR there
, went through no questionsasked.
There were no issues, a singleentry point that sort of
(25:22):
administered the PARs and thatwas running more or less
smoothly.
Stuff, case management,redesign and let's switch 5,000
clients over from this guy tothat guy None of that existed.
We didn't have a public healthemergency and who would have
thought that actually, what cameafter the public health
emergency, with a process thatwas many thought
(25:42):
well-established, caused a muchgreater crisis from a Medicaid
redetermination perspective thanthe pandemic itself?
Times have definitely changed.
Able to efficiently submit yourclaims.
If you're not able to get anelectronic remittance, get it
(26:08):
re-uploaded and then see whereyou got paid and where you
didn't pay and then efficientlyresubmit the portion where you
didn't get paid.
If you're not able to track allthat, you're just going to be
bleeding cash and you're notgoing to be very successful
long-term.
So I think revenue cyclemanagement is definitely very
key, especially in this day andage.
Erin Vallier (26:28):
I think you are spot on there and everybody you
heard it from Alik just makesure you have a good system.
It doesn't matter who it iswhat it is, but you got to have
a good system.
It doesn't matter who it iswhat it is, but you got to have
a good system in place that willhelp you track what's going on
in your business and manage yourclaims and the resubmission of
those claims and help you stayafloat when the continued
(26:51):
pressures from the governmentand the universe mother nature.
If there's another crisis likethat, you just got to be
prepared.
So just want to thank you somuch, alec, for coming on the
show today and sharing all yourknowledge with the listeners.
Alik Kassner (27:06):
Thank you for having me.
Home Health 360 is presented byAlayaCare and hosted by Erin
Vallier.
Erin Vallier (27:13):
First, we want to thank our amazing guests and
listeners.
Alik Kassner (27:17):
Second, our episodes air twice a month, so
be sure to subscribe today soyou don't miss an episode.
Erin Vallier (27:22):
And last but not least, if you liked this episode
and want to learn more aboutall things home-based care, you
can explore all of our episodesat alayacare.
com/homehealth360 or visit us onyour favorite podcast platform.
We were probably one of the first ones to
recognize that, hey, some thingsare going horribly wrong here,
because we saw, as I said, everyfirst of the month, 10, 20, 30
clients getting disenrolled.
Now this is where my reallywide definition of revenue cycle
management kicks in.
(00:20):
This is what I would say.
Processes and people are soimportant, in addition to a good
IT system that helps you trackit all.
We basically introduced adedicated team that started
working with our clients to tryand see why they were getting
disenrolled and what we could doto prevent that from happening.
Erin Vallier (00:52):
Welcome to another episode of the HomeHealth360
podcast, where we speak tohome-based professionals from
around the globe.
I'm your host, Erin Valliere,and today I am joined by Alik
Kassner to talk about bestpractices in revenue cycle
management.
Alik is a co-managing partnerat one of Denver's largest
(01:14):
non-medical family-owned homecare companies.
He holds a master's degree inbusiness from the University of
Toronto and, following a 20-yearcareer in banking, he has been
working in healthcare as anexecutive in Denver since 2012.
Alik is an active member of theHome Care Association, Home
(01:35):
Care and Hospice Association ofColorado, or HHAC.
He's been working on theLegislative and Regulatory
Committee and is activelyinvolved in HHAC's response to
new legislative and regulatorychallenges, as well as being the
association's point person forEVV.
Welcome to the show, Alik.
Alik Kassner (01:57):
Thank you for having me.
Erin Vallier (02:00):
I think you have the relevant background and
success in revenue cyclemanagement to talk about all
things best practices to setpeople up for success.
So let's dive in, let's.
What does revenue cyclemanagement, or RCM, mean in the
context of a home care agency?
Alik Kassner (02:21):
Well, RCM can mean many different things to many
different people.
I can tell you what it means tous here at Alpine.
To us, it's basically the grandtotal of all activities dealing
with the revenue cycle,starting from the structure and
the process, for example, thestructure and the process, for
(02:42):
example, your billing frequency,as opposed to when you are
doing payroll and paying outpayroll.
It covers what are your inputsinto your billing process paper
timesheet, electronic timesheets, what are you using to collect
those?
And obviously also it coversall the IT side, the IT systems
(03:05):
connected to it.
What do you use?
How easy is it to generate abatch billing file that you can
then put into the payer andhopefully get paid at some point
?
And even further, it's not justhow easy or difficult is it to
generate that file for you andyour billing team, but also
(03:25):
afterwards, how easy is it totrack?
Can you, for example, upload anelectronic remittance and then
see where you got paid and whereyou didn't get paid?
And what tools do you have tobasically then track where you
didn't get paid and how easy isit for you to then resubmit
those claims where you didn'tget paid and how easy is it for
(03:45):
you to then resubmit thoseclaims where you didn't get paid
.
That's in a nutshell, I think,what we understand by that, in
our shop at least, Gotcha.
Erin Vallier (03:55):
So it's this big mixture of people, technology
and processes to make sure thatyou get paid, and that can be
incredibly complex at times,which I'm sure we're going to
talk about.
How crucial is effective RCM inthe success of a home care
business?
Alik Kassner (04:12):
Imagine you operate, like we do, in a
relatively thin margin businessright.
Your prices, your Medicaidrates are dictated to you.
Your costs are dictated to youvia caregiver base wages and
other things, and in between iswhere you have to make a living.
And if your processes are notset up correctly, if you
(04:35):
experience unexpected revenueshortfalls and you cannot manage
that properly, you willliterally not make payroll.
And in our business you failyour payroll once.
That means your caregiversdidn't get paid.
Now imagine how motivated thosecaregivers will be to go to
your clients the next day andprovide services.
(04:56):
Probably not very so.
It is absolutely key to have asystem that works, that ensures
that you are a reliable partnerfor your caregivers and your
clients.
Erin Vallier (05:10):
Yeah, that makes sense to me.
If they don't get paid, they'renot going to show up, and the
caregivers are at the heart ofwhat you do.
Alik Kassner (05:16):
Of everything we do.
The caregivers are the mostimportant thing in everything
that we do, absolutely.
Erin Vallier (05:23):
So what are some of the common challenges that
home care agencies face with RCMand at a very high level?
How do you go about addressingthem?
Alik Kassner (05:31):
So I think Alpine has been around now for close to
a quarter of a century and overthat time span I've been there
for now 12 years, so not quitethe entire time, but since I've
been there the events impactingyour revenue have just
quadrupled or quintupled.
(05:52):
There's so much more, so manymore reasons nowadays why your
claims could get rejected.
We've seen the introduction ofelectronic visit verification.
We've seen the introduction ofelectronic visit verification
(06:17):
and once they turn on the claimsedit, which means if something
is missing in your things, youknow that immediately impacts
your revenue cycle, immediatelyimpacts claims.
You won't get paid.
And then there's various otherissues in terms of client
eligibility and PARs that Ithink we can get in a little bit
(06:40):
later.
The grand total of all theseissues that could potentially
impact your claim, that havegotten so much larger over time,
just forces you to have asystem that allows you to
monitor whenever you not getpaid and to then also track and
resubmit these claims.
That's become a lot morecrucial because the instances
(07:04):
where you don't get paid havebecome so much more prevalent
than in the past.
Erin Vallier (07:10):
So a lot of stuff is happening on the regulatory
side that is making it harderfor you to get paid for the hard
work that you do.
I'm sure we're going to getmore into how you can combat
this.
I think what you're hinting ator at least one of them is
something you shared with mewhen we were talking to prepare
(07:31):
for this conversation is theMedicaid disenrollment that
happened when the pandemic ended.
It makes sense, right?
So a lot of people went onMedicaid when they lost their
jobs from the pandemic and sowhen the pandemic was over, it
makes total sense that thosepeople would lose their
enrollment because they got ajob and they're doing all right.
(07:53):
But I heard and I'm sure you cangive me some more intimate
details that there was a majoradministrative boo-boo, if you
will, on the state level thatjust disenrolled a bunch of
people that should not have beendisenrolled.
And I looked into it a littlebit and I think in the state of
(08:14):
Colorado it varied across states, like 8% in Wyoming were
disenrolled up to 82% in Texas.
So there's like all over theboard what happened state by
state.
But in Colorado I couldn't finda hard and fast number, but
somewhere between 42 and 56% ofMedicaid recipients were
disenrolled and two thirds ofthose that lost their coverage
(08:39):
because of an administrativeerror.
How did that impact you and howdid you deal with that?
Because I think this would be aperfect case study in revenue
cycle management.
Alik Kassner (08:51):
Yeah, let's talk about what's going on and is
going on in Colorado.
In Colorado we actually, Ithink we had the perfect storm.
So number one, and certainlythe biggest, is what you've
mentioned the Medicaidredeterminations.
After not having to redetermineMedicaid clients during the
pandemic last summer, the annualredeterminations resumed.
(09:16):
To a lack of staffing on thecounty level, the financial part
of the Medicaid redeterminationdid not happen and many
counties were backlogged and arestill backlogged to this day.
The effect of this is that, asa Medicaid client, even if you
(09:40):
did receive your redeterminationpackage in the mail and let's
be clear, not all people did,but let's say you did and even
if you collected all thedocuments that are necessary
your bank accounts, variousstate plans, utility bills and
so on and so forth and even ifyou submitted all that on time,
(10:01):
whether it's electronically orvia snail mail all that landed
at your county and that's whereit stayed, without anybody
looking at it, for an extendedperiod of time, while your
redetermination period came andwent, and then you were
automatically disembroke.
So that is what happened to agreat number of people and
(10:26):
that's one of the problems thatColorado was facing.
But on top of that, there's twoother things that were going on
.
So also last summer, hicpapHealthcare Policy and Financing
essentially the state ofColorado saying essentially the
(10:47):
state of Colorado, theregulatory authority introduced
a new care and case managementsystem and despite a lot of
testing, that system did notwork as advertised.
So a lot of case managers thatare responsible for the
functional determination justthe other piece in terms of you
need a functional assessment andyou need a financial
(11:08):
eligibility and both togetherthen you can get approved for
your Medicaid services butbecause of CCM not properly
working, they had a verydifficult time doing their job
and we got an email from a casemanagement agency basically
saying hey, we're very sorry,but we may not be able in all
(11:31):
cases to access client records.
Where we can't access clientrecords, we may not be able to
issue a PAR, we may not be ableto change a PAR, we may not be
able to print our power.
We may not be able to print.
Stuff is just a nightmare and Ithink there were 28 known
errors with the system and 42workarounds, and so processes
(11:55):
that under the old system took acase manager of 10 minutes now
took half an hour or longer.
So a really big problem on thatside.
That obviously doesn't helpwith the Medicaid
redeterminations.
And then the third part of theperfect storm was case
management redesign, which is afederal mandate that was getting
(12:17):
implemented here at least thefirst stage in Colorado,
starting November of 2023.
We're mainly a Metro Denverprovider, so I'm just going to
speak for the Metro Denver area.
For Metro Denver, thatbasically means that all clients
in Arapahoe County were movedfrom one case management agency
(12:38):
Rocky Mountain Human Services toanother, to developmental
pathways, and all clients inAdams County were moved from
North Metro to Rocky MountainHuman Services.
The takeaway from this isthousands of Medicaid clients
were moved from one agency toanother with a system CCM care
(13:00):
and case management that is notfully working, on top of which
some of the very same clientswere being automatically
disenrolled because of thebacklog on the county level.
I think this sort of perfectstorm, as I describe it, is, in
a way, a perfect advertisementfor why you need a good revenue
cycle management system.
(13:20):
You need a good revenue cyclemanagement system Because, as a
provider, each first of themonth, we were all faced with a
significant amount of clients.
How significant depends on yoursize, but for us it was 10, 20,
(13:41):
30 clients each first of themonth where you see they're
getting a discontinue in thesystem.
You know and all theregulations say hey, before you
start providing service orcontinue to provide services,
check eligibility and if youlook at eligibility in that
system for those clients, ittells you they're disenrolled.
You are supposed to sellservices.
(14:01):
Now, we are not heartless humanbeings and we at Alpine did
generally not stop services.
But if you're a small provider,do you have a choice?
Because if you do not stopservices, that means you keep
sending your caregiver.
That means you have to keeppaying your caregivers without
(14:24):
you being paid your caregiver.
That means you have to keeppaying your caregivers without
you being paid in return.
So a lot of providers could notdo that.
The reason why Alpine was ableto do it is we were first of all
.
We were like probably one ofthe first ones to recognize that
, hey, some things are goinghorribly wrong here, because we
(14:45):
saw, as I said, every first ofthe month, 10, 20, 30 clients
getting disenrolled.
Now this is where my reallywide definition of revenue cycle
management kicks in.
This is what I would say.
Processes and people are soimportant, in addition to a good
IT system that helps you trackit all.
(15:06):
We basically introduced adedicated team that started
working with our clients to tryand see why they were getting
disenrolled and what we could doto prevent that from happening.
And it turned out pretty quicklythat in most cases the reason
they were getting disenrolled istheir paperwork was at the
(15:27):
county level but nobody waslooking at it.
So we started filing HCPFescalation forms, which at least
initially forced somebody inthe county to look at what was
going on.
They need to pick up the fileand see oh, this is the file for
client XYZ.
There's actually everythinghere I need to complete the
(15:48):
redetermination successfully.
So I'm just going to do thatnow and boom, you got a client
coming back into your revenuecycle because their Medicaid had
just been restored.
It's not quite as easy as I say, because once the Medicaid got
restored they still need to goand have the case management
agency issue the PAR.
(16:09):
So this is where the CCM systemI mentioned earlier was not
very helpful, because sometimesthey couldn't access the info,
they couldn't issue the PAR dueto technical issues and other
things.
But this was helping us gettingclients back.
The other thing that we didthat our team did was we started
(16:32):
filing appeals with the Officeof Administrative Courts, which
sounds really scary becauseyou're going to court to get
your Medicaid back.
But we did that on behalf of ourclients and once again our
experience there was thatprobably around 85% to maybe
even 90% of these appeals thatwe filed got resolved without a
(16:58):
hearing, without a court hearing, and about 10% we and the
client attended these courtappearances.
Thankfully they were virtual,so it's like you had to go to
the courthouse of the client.
He could be on Zoom and helpthe client get on, and I think
we still have 100% success ratioin these appeals.
Yeah, in part because, again,this is not the fault of the
(17:23):
client.
The client had submittedeverything, like the cases where
there's something missing orthe client had forgotten to
submit something or the case youdescribed in the beginning,
somebody who lost their job andthen, after the pandemic, they
resumed their job, they got itback and now they earn too much
to make.
Medicaid virtually didn't existin our world.
(17:44):
Our clients are all elderlypeople.
They're all on the elderly,disabled and blind waiver most
of them, and nothing changed.
They didn't win the lotterysince the pandemic.
So all our cases were reallyclear.
What basically ended uphappening was back now.
(18:06):
We filed over 160 appeals andover 80 Hickapuff escalation
forms, and this is a processthat was ongoing basically since
last fall and where it then allkind of ties together is each
(18:35):
month.
Not only did we see, oh, we'relosing another 30 clients and
how we're going to make payroll,but we also saw 10, 20 clients
coming back good enough to trackmultiple.
We literally had to submit someclaims, probably 10 to 15 times
, and we were able to track allthat, and not only track what we
needed to resubmit and what wegot paid and the clients that
(18:57):
were coming back as opposed tothe ones that're losing, but we
were also able to relativelyaccurately forecast, okay, what
are we going to get paid in thisnext cycle, as opposed to what
our payroll was going to be.
And, long story short, all ofthis combined allowed us to not
(19:20):
having to suspend services toour clients.
That's a really big dealbecause we look around and a lot
of people had to suspendservices.
We understand those reasonsvery well.
They were threatening us aswell, but because of our
approach we were able tocontinue and there was help from
(19:40):
HICPA, from the state.
You could take out a loan, butyou know very well a loan
doesn't really help you if,number one, you have to pay it
back.
Number two, if it doesn't breakthe trend that every month you
lose many more clients, theireligibility goes away but you
can't get them back and youdon't have enough money to make
payroll, other than maybe fromthe loan.
(20:02):
But that's going to run outeventually and the state is
going to take it back out of therevenue that you're supposed to
generate In our view thatwasn't really a solution or not
the optimal solution, and wefelt very vindicated when
finally the state in March Aprilso a month, only a month or two
(20:23):
ago finally figured out okay,we really need to do something,
and started with automaticextensions of Medicaid,
redeterminations and eligibility, automatic PAR extensions, and
they also did some automaticreprocessing mass reprocessing
of previously submitted claims.
And I think they did it two orthree times since then and both
(20:48):
times we got tremendous amountof money back of unpaid claims,
to the extent that I think we'renow basically 95% all paid up.
And the most surprising thingfor us is when I talked to some
of my colleagues, they're likeno, we didn't really benefit
from that, we didn't really seean improvement, and the reason
(21:08):
why they didn't and we did isbecause they stopped services.
So if they stopped servicesthen of course they're not
getting reimbursed for anythingright now.
Erin Vallier (21:18):
I would agree you took a very expansive and
creative approach to it, and itwas risky too, because if you
provide services and they're notcovered, then you run a high
risk of never getting reimbursed.
So that took a little bit ofbravery there, and then some
creativity, to have a teamassembled who was just dedicated
(21:39):
to doing something that not alot of other agencies do,
because it's my understandingthat it's not very common to be
that hands-on with the client toget them redetermined and also
to do those appeals.
I don't think very many otherpeople go to that length, but
this is just definitely a greatcase study in what is possible
(22:02):
if you're willing to just rollup your sleeves and do something
a little bit outside the box.
I want to talk a little bitmore about technology, because
you've mentioned it a coupletimes.
How do you leverage technologyto streamline your RCM process?
Alik Kassner (22:16):
I think that's just that you need to have the
technology to support yourregular efforts, your team's
efforts.
If you cannot track what you'redoing with all these appeals
and redeterminations, if youcannot resubmit repeatedly and
easily once you've got Medicaidand the PAR restored, if you
(22:39):
can't track and if you can'tforecast the effects of it all,
then you're not going to be verysuccessful.
You're still flying blind.
You still won't know if youhave enough money to make
payroll.
So technology having a goodsystem, I think is very much key
in all of this.
Erin Vallier (22:57):
We'll submit for you, resubmit for you and then
track.
So let's talk about tracking.
What are some of the KPIs, orkey performance indicators, that
you use to track the financialhealth of your agency?
Alik Kassner (23:12):
We use a fair amount of indicators.
I'd like to think at least someof them are key.
But we basically monitor ourclients, the number of our
clients' hours, so service hours.
We obviously monitor veryclosely revenue and cost.
We obviously monitor intake.
(23:33):
We monitor sort of thepercentage of what we get paid
on.
We also have measures in termsof profitability by client,
although, to be honest, in theMedicaid world a lot of the
clients, the rates, are the same.
The only differential there isbasically usually the hours.
(23:56):
The caregivers make more orless the same plus minus a
dollar or two.
But yeah, you can track a lotof things.
I think for us the mostimportant ones are the ones I
mentioned.
Erin Vallier (24:10):
So what's coming in and what's going out, and it
better be in the green right.
Alik Kassner (24:14):
It better be in the green, but also the hours.
Are we increasing our hours?
Are we not increasing our hours?
And then we have a great dealof many different payer sources,
at least for an agency of oursize, and you have to be able to
obviously also administer andtrack those.
Erin Vallier (24:35):
We've covered a lot of stuff in our conversation
so far today.
I just have one final questionfor you, Based on your
experience what advice would youoffer other agency owners or
administrators who are lookingto improve their revenue cycle
management practices?
Alik Kassner (24:53):
Have a good system .
It sounds simple, right, butagain, if you just look back,
maybe five, even six years, noneof these problems existed.
You didn't have EVV, so yourclaims, if there was a PAR there
, went through no questionsasked.
There were no issues, a singleentry point that sort of
(25:22):
administered the PARs and thatwas running more or less
smoothly.
Stuff, case management,redesign and let's switch 5,000
clients over from this guy tothat guy None of that existed.
We didn't have a public healthemergency and who would have
thought that actually, what cameafter the public health
emergency, with a process thatwas many thought
(25:42):
well-established, caused a muchgreater crisis from a Medicaid
redetermination perspective thanthe pandemic itself?
Times have definitely changed.
Able to efficiently submit yourclaims.
If you're not able to get anelectronic remittance, get it
(26:08):
re-uploaded and then see whereyou got paid and where you
didn't pay and then efficientlyresubmit the portion where you
didn't get paid.
If you're not able to track allthat, you're just going to be
bleeding cash and you're notgoing to be very successful
long-term.
So I think revenue cyclemanagement is definitely very
key, especially in this day andage.
Erin Vallier (26:28):
I think you are spot on there and everybody you
heard it from Alik just makesure you have a good system.
It doesn't matter who it iswhat it is, but you got to have
a good system.
It doesn't matter who it iswhat it is, but you got to have
a good system in place that willhelp you track what's going on
in your business and manage yourclaims and the resubmission of
those claims and help you stayafloat when the continued
(26:51):
pressures from the governmentand the universe mother nature.
If there's another crisis likethat, you just got to be
prepared.
So just want to thank you somuch, alec, for coming on the
show today and sharing all yourknowledge with the listeners.
Alik Kassner (27:06):
Thank you for having me.
Home Health 360 is presented byAlayaCare and hosted by Erin
Vallier.
Erin Vallier (27:13):
First, we want to thank our amazing guests and
listeners.
Alik Kassner (27:17):
Second, our episodes air twice a month, so
be sure to subscribe today soyou don't miss an episode.
Erin Vallier (27:22):
And last but not least, if you liked this episode
and want to learn more aboutall things home-based care, you
can explore all of our episodesat alayacare.
com/homehealth360 or visit us onyour favorite podcast platform.
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