Situation

Client owns, operates and manages several Medicare and Medicaid participating skilled nursing facilities and rehabilitation hospitals. Client endeavored to outsource its third party cost reporting function and to obtain third party reimbursement planning assistance.

Concerns

Client was concerned that its existing resources were not sufficient to adequately meet all of its third party reimbursement reporting requirements and to provide for necessary Medicaid rate setting planning.

Services

After an extensive request for proposal process, The Lancaster Group was engaged to perform the following services:

• Timely file all Medicare and Medicaid Cost Reports and Home Office Cost Statement.
• Upgrade Medicare bad debt reimbursement claiming practices.
• Assist with the appeal of prior years' cost report adjustments.
• Make all cost reporting year ends consistent.
• Resolve outstanding change of ownership and change of information issues.
• File amended Medicaid capital reports in support of requests for increased Medicaid capital reimbursement.

The Lancaster Group successfully completed all of the tasks requested by Client, including the timely filing of all cost reports, including an extensive pre-filing review of Medicare bad debt claims, the successful appeal of the Medicare adjustments to the rehabilitation hospitals' LIP percentages, changing the cost report year end of one of the Medicare providers, resolved the freestanding status of one of the skilled nursing facilities and obtained increased Medicaid capital reimbursement for the two Medicaid providers.

Outsourced Third Party Billing

Situation

Client has struggled collecting its third party accounts receivable. Specifically, 85% - 95% of claims have historically been collected, with the balance going unpaid and ultimately written off. Periodic turnover in the business office has led to decreased billing and collections performance.

Concerns

Client was concerned that without external assistance, cash flow would continue to suffer and that large collectible balances would become stale and uncollectible.

Services

The Lancaster Group was engaged to perform the following services:

• Clean-up the accounts receivable aging report, by identifying and correcting mis-postings and identifying balances in need of write off.
• Bill and collect outstanding accounts receivable, including difficult managed care claims.
• Create a process for the timely accumulation of necessary billing data and follow-up on initially denied claims.
• Perform third party billing function on an outsourced basis, using a combination of on-site activities and remote access.
• Prepare and file Medicare Secondary Payor claims, Medicare No-Pay claims, Medicare bad debt logs and quarterly credit balance reports.

Results

The Lancaster Group successfully completed all of the tasks requested by Client, and continues to provide the third party billing function on an outsourced basis. All legitimate unpaid claims were researched, billed and collected, resulting in a material decrease in the amount of outstanding accounts receivable and therefore improving the Client's cash flow.

Survey Clearance

Situation

Client owns, operates, and manages several Medicare and Medicaid participating skilled nursing facilities. A complaint survey resulted in one of the Client's nursing facilities to be in noncompliance regarding medication administration to its residents. The survey resulted in 10 Immediate Jeopardy deficiencies and heavy fines.

Concerns

Client was concerned that the nursing staff was lacking education, motivation, and tools to perform their jobs adequately and to stay in compliance on a daily basis. The Client knew that medication administration needed to be next-to-perfect to ensure the clearance of the outstanding deficiencies and that processes needed to be implemented to prevent future similar deficiencies from occurring.

Services

The Lancaster Group was engaged to perform the following services by our registered nurse:

• Initial evaluation of the medication carts.
• Twice-per-week complete audit of the medication carts.
• Weekly medication pass observation of the day and evening shifts.
• Bi-weekly auditing of the Medication Administration Records.
• Meet with institutional pharmacy provider and resolve ordering and delivery deficits by implementing improved processes.
• Implement an improved system for verifying medications.
• Create a medication report sheet to be completed at every shift.
• Periodic verification of early morning delivery invoices and consultation with staff nurses regarding any medications ordered, but not delivered.
• Conduct bi-weekly inservices to all nurses involved in medication administration to reinforce the new system as well as to motivate them by recognizing them for doing well and stressing to them their importance in the residents' lives as well as the responsibility they held for carrying a nursing license.

Results

All tasks as requested by the Client were completed and notably the Client's staff were successfully motivated to be diligent in improving their medication administration skills and documentation skills. Staff were educated on the responsibilities they held in carrying a nursing license and the importance of following physician orders in order to maintain their licenses. The first day of the follow-up survey, the surveyors commented that it was evident that the facility had been working very hard on improving all aspects of medication administration since they had not found anything that was less than perfect. The second day of the follow-up survey resulted in all 10 Immediate Jeopardy deficiencies being cleared with complimentary remarks made by the surveyors.

Business Planning

Situation

Client owns and operates several skilled nursing facilities. Client was considering the replacement of certain of its facilities and the addition of ancillary services to its current business lines.

Concerns

Client was concerned about the ability to finance the replacement facilities and whether sufficient resources existed to undertake the additional ancillary service business lines.

Services

The Lancaster Group was engaged to evaluate the financial projections of the replacement facilities and of the proposed ancillary service business lines.

Results

The Lancaster Group provided the requested services and met with the Client and its lender to present the financial projections for the replacement facilities. The Client was able to successfully finance the replacement facilities. Additionally, The Lancaster Group recommended that the Client's existing resources were not sufficient to undertake the proposed ancillary service business lines and offered recommendations regarding the changes that would need to be made in preparation for undertaking the new business lines.

Systems Implementation and Ongoing Performance

Situation

Client owns and operates several skilled nursing facilities and related ancillary businesses. Client experienced severe difficulties with regulatory filings, claims for business interruption insurance proceeds and compiling monthly financial statements. Client was operating without a Chief Financial Officer.

Concerns

Client was concerned that existing resources would not be sufficient to complete the necessary tasks required of a multi-site provider and that continued deficits would lead to a reduction in cash flow and ongoing operating performance.

Services

The Lancaster Group was engaged to perform an assessment of Client's finance department and its use of available computer systems.

Results

The Lancaster Group performed the requested assessment and identified deficits in existing skill sets, allocation of responsibilities, use of consistent policies and procedures and less-than-optimal use of computer software systems. The Lancaster Group was subsequently engaged to assist in the implementation of its recommendations, including fulfilling the role of interim Chief Financial Officer.

Financial, Operating and Regulatory Due Diligence

Situation

Client endeavored to purchase a skilled nursing facility, operating in one state, with significant neighboring state Medicaid utilization. Client wished to assume the Medicare provider number and to obtain new Medicaid provider numbers.

Concerns

Client was concerned about the target's medical documentation practices in support of its third party billing, neighboring state Medicaid rate setting on a post-transactional basis, quality of earnings for loan underwriting purposes and ongoing expense structure.

Services

The Lancaster Group was engaged to perform the following services to address Client's concerns.

• Medical record review for purposes of determining whether documentation was sufficient to support Medicare billing and Medicare and Medicaid minimum data set documentation and completion practices.
• Evaluation of the billing compliance policies, procedures and practices to identify areas in which improvement would be recommended.
• Evaluation of auditor work papers, aged accounts receivable and allowance for doubtful accounts to determine reasonableness of net realizable revenue projections, estimate of future Medicaid reimbursement rates and evaluation of the billing for medical ancillary services to identify areas in which additional revenue opportunities may exist.
• Analysis of staffing and other expenses to verify proper accounting and to identify areas in which expenses may be expected to vary from historical experience.

The Lancaster Group was able to assist Client in successfully acquiring the skilled nursing facility, by performing the requested services and by assisting with negotiation of the purchase and sale agreement, evaluating proposals for financing, identifying opportunities for improvement and assisting with the various required regulatory filings.

Accounts Receivable Collections/Clean-up

Situation

Client operates and manages several Medicare and Medicaid participating skilled nursing facilities. Client experienced difficulties in managing and performing the collections process.

Concerns

Client was concerned that its accounts receivable was growing considerably and would result in an increase in bad debt expense.

Services

The Lancaster Group was engaged to perform the following services:

• Supervise and assist in the current month end billing process.
• Research and assist in the correction and submission of claims.
• Identify AR balances that were not collectible and prepare documentation for write off.
• Implement a monthly review process to identify denied claims timely and assist in corrections.
• Implement a weekly process that identifies tasks to be completed in an accurate and timely manner.
• Educate the Administrator and key personnel to understand the issues causing collection problems.
• Provide continued oversight to ensure collections success.

The Lancaster Group was successful in assisting the client to:

• Increase cash flow.
• Reduce aged receivables.
• Implement policies and procedures to ensure the accurate and timely collection of A/R.
• Educate the Administrative team in the ongoing support of the Business Office’s collection activities.