Medicaid reimbursement plays a significant role in the financial health of long-term care facilities, particularly those serving a high percentage of Medicaid residents. While it may not be the sole source of revenue, it is an important component that supports the sustainability of facilities and ensures they can continue providing care to residents who rely on Medicaid coverage.

 

Optimizing Reimbursement

By focusing on three key areas – insurance verification, optimizing the Case Mix Index (CMI), and maintaining a balanced resident acuity – facilities can strengthen their financial stability while ensuring high-quality care for residents.

1. Insurance Verification: Laying the Foundation

    • Eligibility Check: Confirm Medicaid eligibility using state systems, reviewing coverage details to avoid delays in reimbursement.
    • Documentation: Collect and maintain accurate records – including proof of application submission, enrollment, and medical records – to ensure compliance.
    • Ongoing Monitoring: Implement periodic reviews for re-certification to maintain continued eligibility and avoid coverage lapses.

Accurate and thorough insurance verification ensures facilities can secure timely reimbursements.

 

2. Optimizing Case Mix Index (CMI): Identifying High-Acuity Residents

    • Pre-Admissions Screening: Conduct a detailed medical record review to ensure that the resident’s diagnoses, medical conditions, and care needs are accurately documented. Identify if the resident has complex conditions such as neurological disorders, chronic wounds, or respiratory conditions with needs.
    • Thorough Documentation: Verify that all medical conditions and treatments are accurately determined and documented by the physician. This includes reviewing medical records to confirm that the resident is receiving appropriate care or treatment for diagnoses recorded as active in the medical record.

By selecting residents with higher acuity, facilities can optimize their CMI and secure fair compensation for the care provided.

 

3. Maintaining a Balanced Resident Mix

    • Variety in Admissions: Admit a mix of Medicaid residents with both higher and lower acuity levels to maintain a balanced care environment.
    • Efficient Resource Allocation: Ensure that staff and resources are effectively distributed to meet the needs of all residents, preventing overburdening and ensuring high-quality care.
    • Financial Stability: A balanced resident mix stabilizes the facility’s financial health by optimizing Medicaid reimbursement and managing the risks associated with relying solely on high-acuity residents.

Maintaining a balanced resident mix allows facilities to enhance their financial health while delivering individualized, high-quality care to all residents.

Strategic Admissions

Effective admission management is key to optimizing Medicaid reimbursement. By verifying insurance, targeting high-acuity residents, and maintaining a balanced variety in resident acuity, long-term care facilities can enhance their financial stability and ensure compliance with Medicaid guidelines. These strategies not only improve reimbursement but also contribute to the overall quality of care provided to residents.

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