Alik Kassner: 0:00
We were probably one of the first ones to recognize that, hey, some things are going horribly wrong here, because we saw, as I said, every first of the month, 10, 20, 30 clients getting disenrolled. Now this is where my really wide definition of revenue cycle management kicks in. This is what I would say. Processes and people are so important, in addition to a good IT system that helps you track it all. We basically introduced a dedicated team that started working with our clients to try and see why they were getting disenrolled and what we could do to prevent that from happening.
Erin Vallier: 0:52
Welcome to another episode of the HomeHealth360 podcast, where we speak to home-based professionals from around the globe. I’m your host, Erin Valliere, and today I am joined by Alik Kassner to talk about best practices in revenue cycle management. Alik is a co-managing partner at one of Denver’s largest non-medical family-owned home care companies. He holds a master’s degree in business from the University of Toronto and, following a 20-year career in banking, he has been working in healthcare as an executive in Denver since 2012. Alik is an active member of the Home Care Association, Home Care and Hospice Association of Colorado, or HHAC. He’s been working on the Legislative and Regulatory Committee and is actively involved in HHAC’s response to new legislative and regulatory challenges, as well as being the association’s point person for EVV. Welcome to the show, Alik.
Alik Kassner: 1:57
Thank you for having me.
Erin Vallier: 2:00
I think you have the relevant background and success in revenue cycle management to talk about all things best practices to set people up for success. So let’s dive in, let’s. What does revenue cycle management, or RCM, mean in the context of a home care agency?
Alik Kassner: 2:21
Well, RCM can mean many different things to many different people. I can tell you what it means to us here at Alpine. To us, it’s basically the grand total of all activities dealing with the revenue cycle, starting from the structure and the process, for example, the structure and the process, for example, your billing frequency, as opposed to when you are doing payroll and paying out payroll. It covers what are your inputs into your billing process paper timesheet, electronic timesheets, what are you using to collect those? And obviously also it covers all the IT side, the IT systems connected to it. What do you use?
Alik Kassner: 3:08
How easy is it to generate a batch billing file that you can then put into the payer and hopefully get paid at some point? And even further, it’s not just how easy or difficult is it to generate that file for you and your billing team, but also afterwards, how easy is it to track? Can you, for example, upload an electronic remittance and then see where you got paid and where you didn’t get paid? And what tools do you have to basically then track where you didn’t get paid and how easy is it for you to then resubmit those claims where you didn’t get paid and how easy is it for you to then resubmit those claims 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: 3:55
So it’s this big mixture of people, technology and processes to make sure that you 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 in the success of a home care business?
Alik Kassner: 4:12
Imagine you operate, like we do, in a relatively thin margin business right. Your prices, your Medicaid rates are dictated to you. Your costs are dictated to you via caregiver base wages and other things, and in between is where you have to make a living. And if your processes are not set up correctly, if you experience unexpected revenue shortfalls and you cannot manage that properly, you will literally not make payroll. And in our business you fail your payroll once. That means your caregivers didn’t get paid. Now imagine how motivated those caregivers will be to go to your clients the next day and provide services. Probably not very so. It is absolutely key to have a system that works, that ensures that you are a reliable partner for your caregivers and your clients.
Erin Vallier: 5:10
Yeah, that makes sense to me. If they don’t get paid, they’re not going to show up, and the caregivers are at the heart of what you do.
Alik Kassner: 5:16
Of everything we do. The caregivers are the most important thing in everything that we do, absolutely.
Erin Vallier: 5:23
So what are some of the common challenges that home care agencies face with RCM and at a very high level? How do you go about addressing them?
Alik Kassner: 5:31
So I think Alpine has been around now for close to a quarter of a century and over that time span I’ve been there for now 12 years, so not quite the entire time, but since I’ve been there the events impacting your revenue have just quadrupled or quintupled.
Alik Kassner: 5:52
There’s so much more, so many more reasons nowadays why your claims could get rejected. We’ve seen the introduction of electronic visit verification. We’ve seen the introduction of electronic visit verification and once they turn on the claims edit, which means if something is missing in your things, you know that immediately impacts your revenue cycle, immediately impacts claims. You won’t get paid. And then there’s various other issues in terms of client eligibility and PARs that I think we can get in a little bit later. The grand total of all these issues that could potentially impact your claim, that have gotten so much larger over time, just forces you to have a system that allows you to monitor whenever you not get paid and to then also track and resubmit these claims. That’s become a lot more crucial because the instances where you don’t get paid have become so much more prevalent than in the past.
Erin Vallier: 7:10
So a lot of stuff is happening on the regulatory side that is making it harder for you to get paid for the hard work that you do. I’m sure we’re going to get more into how you can combat this. I think what you’re hinting at or at least one of them is something you shared with me when we were talking to prepare for this conversation is the Medicaid disenrollment that happened when the pandemic ended. It makes sense, right? So a lot of people went on Medicaid when they lost their jobs from the pandemic and so when the pandemic was over, it makes total sense that those people would lose their enrollment because they got a job and they’re doing all right.
Erin Vallier: 7:53
But I heard and I’m sure you can give me some more intimate details that there was a major administrative boo-boo, if you will, on the state level that just disenrolled a bunch of people that should not have been disenrolled. And I looked into it a little bit and I think in the state of Colorado it varied across states, like 8% in Wyoming were disenrolled up to 82% in Texas. So there’s like all over the board what happened state by state. But in Colorado I couldn’t find a hard and fast number, but somewhere between 42 and 56% of Medicaid recipients were disenrolled and two thirds of those that lost their coverage because of an administrative error. How did that impact you and how did you deal with that? Because I think this would be a perfect case study in revenue cycle management.
Alik Kassner: 8:51
Yeah, let’s talk about what’s going on and is going on in Colorado. In Colorado we actually, I think we had the perfect storm. So number one, and certainly the biggest, is what you’ve mentioned the Medicaid redeterminations. After not having to redetermine Medicaid clients during the pandemic last summer, the annual redeterminations resumed. To a lack of staffing on the county level, the financial part of the Medicaid redetermination did not happen and many counties were backlogged and are still backlogged to this day. The effect of this is that, as a Medicaid client, even if you did receive your redetermination package in the mail and let’s be clear, not all people did, but let’s say you did and even if you collected all the documents that are necessary your bank accounts, various state plans, utility bills and so on and so forth and even if you submitted all that on time, whether it’s electronically or via snail mail all that landed at your county and that’s where it stayed, without anybody looking at it, for an extended period of time, while your redetermination period came and went, and then you were automatically disembroke. So that is what happened to a great number of people and that’s one of the problems that Colorado was facing. But on top of that, there’s two other things that were going on. So also last summer, hicpap Healthcare Policy and Financing essentially the state of Colorado saying essentially the state of Colorado, the regulatory authority introduced a new care and case management system and despite a lot of testing, that system did not work as advertised. So a lot of case managers that are responsible for the functional determination just the other piece in terms of you need a functional assessment and you need a financial eligibility and both together then you can get approved for your Medicaid services but because of CCM not properly working, they had a very difficult time doing their job and we got an email from a case management agency basically saying hey, we’re very sorry, but we may not be able in all cases to access client records. Where we can’t access client records, we may not be able to issue a PAR, we may not be able to 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 I think there were 28 known errors with the system and 42 workarounds, and so processes that under the old system took a case manager of 10 minutes now took half an hour or longer. So a really big problem on that side. That obviously doesn’t help with the Medicaid redeterminations.
Alik Kassner: 12:09
And then the third part of the perfect storm was case management redesign, which is a federal mandate that was getting implemented here at least the first stage in Colorado, starting November of 2023. We’re mainly a Metro Denver provider, so I’m just going to speak for the Metro Denver area. For Metro Denver, that basically means that all clients in Arapahoe County were moved from one case management agency Rocky Mountain Human Services to another, to developmental pathways, and all clients in Adams County were moved from North Metro to Rocky Mountain Human Services. The takeaway from this is thousands of Medicaid clients were moved from one agency to another with a system CCM care and case management that is not fully working, on top of which some of the very same clients were being automatically disenrolled because of the backlog on the county level. I think this sort of perfect storm, as I describe it, is, in a way, a perfect advertisement for why you need a good revenue cycle management system. You need a good revenue cycle management system Because, as a provider, each first of the month, we were all faced with a significant amount of clients.
Alik Kassner: 13:32
How significant depends on your size, but for us it was 10, 20, 30 clients each first of the month where you see they’re getting a discontinue in the system. You know and all the regulations say hey, before you start providing service or continue to provide services, check eligibility and if you look at eligibility in that system for those clients, it tells you they’re disenrolled. You are supposed to sell services. Now, we are not heartless human beings 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 stop services, that means you keep sending your caregiver. That means you have to keep paying your caregivers without you being paid your caregiver. That means you have to keep paying your caregivers without you being paid in return. So a lot of providers could not do that.
Alik Kassner: 14:32
The reason why Alpine was able to do it is we were first of all. We were like probably one of the first ones to recognize that, hey, some things are going horribly wrong here, because we saw, as I said, every first of the month, 10, 20, 30 clients getting disenrolled. Now this is where my really wide definition of revenue cycle management kicks in. This is what I would say. Processes and people are so important, in addition to a good IT system that helps you track it all. We basically introduced a dedicated team that started working with our clients to try and see why they were getting disenrolled and what we could do to prevent that from happening.
Alik Kassner: 15:20
And it turned out pretty quickly that in most cases the reason they were getting disenrolled is their paperwork was at the county level but nobody was looking at it.
Alik Kassner: 15:31
So we started filing HCPF escalation forms, which at least initially forced somebody in the county to look at what was going on. They need to pick up the file and see oh, this is the file for client XYZ. There’s actually everything here I need to complete the redetermination successfully. So I’m just going to do that now and boom, you got a client coming back into your revenue cycle 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 go and have the case management agency issue the PAR. So this is where the CCM system I mentioned earlier was not very helpful, because sometimes they couldn’t access the info, they couldn’t issue the PAR due to technical issues and other things. But this was helping us getting clients back. The other thing that we did that our team did was we started filing appeals with the Office of Administrative Courts, which sounds really scary because you’re going to court to get your Medicaid back.
Alik Kassner: 16:42
But we did that on behalf of our clients and once again our experience there was that probably around 85% to maybe even 90% of these appeals that we filed got resolved without a hearing, without a court hearing, and about 10% we and the client attended these court appearances. Thankfully they were virtual, so it’s like you had to go to the courthouse of the client. He could be on Zoom and help the client get on, and I think we still have 100% success ratio in these appeals. Yeah, in part because, again, this is not the fault of the client.
Alik Kassner: 17:23
The client had submitted everything, like the cases where there’s something missing or the client had forgotten to submit something or the case you described in the beginning, somebody who lost their job and then, after the pandemic, they resumed their job, they got it back and now they earn too much to make. Medicaid virtually didn’t exist in our world. Our clients are all elderly people. They’re all on the elderly, disabled and blind waiver most of them, and nothing changed. They didn’t win the lottery since the pandemic. So all our cases were really clear.
Alik Kassner: 18:02
What basically ended up happening was back now. We filed over 160 appeals and over 80 Hickapuff escalation forms, and this is a process that was ongoing basically since last fall and where it then all kind of ties together is each month. Not only did we see, oh, we’re losing another 30 clients and how we’re going to make payroll, but we also saw 10, 20 clients coming back good enough to track multiple. We literally had to submit some claims, probably 10 to 15 times, and we were able to track all that, and not only track what we needed to resubmit and what we got paid and the clients that were coming back as opposed to the ones that’re losing, but we were also able to relatively accurately forecast, okay, what are we going to get paid in this next cycle, as opposed to what our payroll was going to be.
Alik Kassner: 19:13
And, long story short, all of this combined allowed us to not having to suspend services to our clients. That’s a really big deal because we look around and a lot of people had to suspend services. We understand those reasons very well. They were threatening us as well, but because of our approach we were able to continue and there was help from HICPA, from the state. You could take out a loan, but you 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 break the trend that every month you lose many more clients, their eligibility goes away but you can’t get them back and you don’t have enough money to make payroll, other than maybe from the loan.
Alik Kassner: 20:02
But that’s going to run out eventually and the state is going to take it back out of the revenue that you’re supposed to generate In our view that wasn’t really a solution or not the optimal solution, and we felt very vindicated when finally the state in March April so a month, only a month or two ago finally figured out okay, we really need to do something, and started with automatic extensions of Medicaid, redeterminations and eligibility, automatic PAR extensions, and they also did some automatic reprocessing mass reprocessing of previously submitted claims. And I think they did it two or three times since then and both times we got tremendous amount of money back of unpaid claims, to the extent that I think we’re now basically 95% all paid up. And the most surprising thing for us is when I talked to some of my colleagues, they’re like no, we didn’t really benefit from that, we didn’t really see an improvement, and the reason why they didn’t and we did is because they stopped services. So if they stopped services then of course they’re not getting reimbursed for anything right now.
Erin Vallier: 21:18
I would agree you took a very expansive and creative approach to it, and it was risky too, because if you provide services and they’re not covered, then you run a high risk of never getting reimbursed. So that took a little bit of bravery there, and then some creativity, to have a team assembled who was just dedicated to doing something that not a lot of other agencies do, because it’s my understanding that it’s not very common to be that hands-on with the client to get them redetermined and also to do those appeals. I don’t think very many other people go to that length, but this is just definitely a great case study in what is possible if you’re willing to just roll up your sleeves and do something a little bit outside the box. I want to talk a little bit more about technology, because you’ve mentioned it a couple times. How do you leverage technology to streamline your RCM process?
Alik Kassner: 22:16
I think that’s just that you need to have the technology to support your regular efforts, your team’s efforts. If you cannot track what you’re doing with all these appeals and redeterminations, if you cannot resubmit repeatedly and easily once you’ve got Medicaid and the PAR restored, if you can’t track and if you can’t forecast the effects of it all, then you’re not going to be very successful. You’re still flying blind. You still won’t know if you have enough money to make payroll. So technology having a good system, 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, or key performance indicators, that you use to track the financial health of your agency?
Alik Kassner: 23:12
We use a fair amount of indicators. I’d like to think at least some of them are key. But we basically monitor our clients, the number of our clients’ hours, so service hours. We obviously monitor very closely revenue and cost. We obviously monitor intake. We monitor sort of the percentage of what we get paid on. We also have measures in terms of profitability by client, although, to be honest, in the Medicaid world a lot of the clients, the rates, are the same. The only differential there is basically usually the hours. The caregivers make more or less the same plus minus a dollar or two. But yeah, you can track a lot of things. I think for us the most important 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 deal of many different payer sources, at least for an agency of our size, and you have to be able to obviously also administer and track those.
Erin Vallier: 24:35
We’ve covered a lot of stuff in our conversation so far today. I just have one final question for you, Based on your experience what advice would you offer other agency owners or administrators who are looking to improve their revenue cycle management practices?
Alik Kassner: 24:53
Have a good system. It sounds simple, right, but again, if you just look back, maybe five, even six years, none of these problems existed. You didn’t have EVV, so your claims, if there was a PAR there, went through no questions asked. There were no issues, a single entry point that sort of administered the PARs and that was running more or less smoothly. Stuff, case management, redesign and let’s switch 5,000 clients over from this guy to that guy None of that existed. We didn’t have a public health emergency and who would have thought that actually, what came after the public health emergency, with a process that was many thought well-established, caused a much greater crisis from a Medicaid redetermination perspective than the pandemic itself? Times have definitely changed. Able to efficiently submit your claims. If you’re not able to get an electronic remittance, get it re-uploaded and then see where you got paid and where you didn’t pay and then efficiently resubmit the portion where you didn’t get paid. If you’re not able to track all that, you’re just going to be bleeding cash and you’re not going to be very successful long-term.
Alik Kassner: 26:21
So I think revenue cycle management is definitely very key, especially in this day and age.
Erin Vallier: 26:28
I think you are spot on there and everybody you heard it from Alik just make sure you have a good system. It doesn’t matter who it is what it is, but you got to have a good system. It doesn’t matter who it is what it is, but you got to have a good system in place that will help you track what’s going on in your business and manage your claims and the resubmission of those claims and help you stay afloat when the continued pressures from the government and the universe mother nature. If there’s another crisis like that, you just got to be prepared. So just want to thank you so much, alec, for coming on the show today and sharing all your knowledge with the listeners.
Alik Kassner: 27:06
Thank you for having me. Home Health 360 is presented by AlayaCare 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 so you don’t miss an episode.
Erin Vallier: 27:22
And last but not least, if you liked this episode and want to learn more about all things home-based care, you can explore all of our episodes at alayacare. com/homehealth360 or visit us on your favorite podcast platform.
