It Ain’t Over ‘Til its Covered – Medicare Advantage and COVID-19

It Ain’t Over ‘Til its Covered

Medicare Advantage and COVID-19


Yogi Berra is famous for saying quotes that sometimes we didn’t understand. And one of the things that he said was: If you see a fork in the road, take it.

Now. I’m not sure what that means.

I don’t even know if he knew what that meant, but I think I’m going to take his advice anyway.

I’m stuck at a fork.

On the one hand, it seems like Medicare advantage plans were really looking to help their membership throughout the COVID crisis, with whatever they can do. They were offering transportation, they were offering food, they were waving a lot of out of pocket costs. They were trying to keep in touch with membership throughout the crisis to see if they can help them with anything that they can. And it really shows the value that a Medicare advantage plan can really offer in the healthcare market.

On the other hand, some people are looking at this and saying: One second, Medicare advantage plans were really doing well during this crisis. There was very low hospitalizations — aside for COVID related hospitalizations. People were avoiding any elective surgery or doctor visits at all costs. So insurance companies are in the business of getting paid and only paying out when there’s a claim for them to pay for care that was provided. They were really doing well. They were cashing in, but not having to pay out too much. So that is the opinion of some people.

Therefore we’re stuck at a fork, which way do we go? And we’re going to take it.

I’m going to tell you how we can figure this out by ourselves. And that is, let’s give it some time. Because as hopefully COVID will be further and further in the rear view mirror, let’s hope. what’s going to happen is that we can watch and see: Will the Medicare advantage plans continue to offer similar benefits and advantages to their membership even as the hospitalizations are on an uptick or perhaps the claims are coming in more regularly? Will they still continue to add these kinds of benefits? If they do, we know what their motivation was throughout.

So I think we can just give this some time. and we’ll see exactly how the insurance companies will treat their membership for the long haul.

And as Yogi famously says, you can observe a lot by watching.

Let’s watch and see what happens.

And thank you so much for watching this. Let me know what you think in the comments.


Steve Shain is the Chief Operating Officer of LTC Contracting.

LTC Contracting guides providers through licensure and business setup procedures and ensures compliance with all regulations, whether the providers are opening new organizations or adding new service lines to their existing businesses. LTC’s services also include getting providers credentialed and on the Managed Care Organizations’ (MCOs’) networks.

The Top 3 Causes for Aging AR in SNFs

Where’s the Cash? The Top 3 Causes for Aging AR in SNFs


As a team of outsourced AR professionals, we get asked this question constantly here at LTC Collections.

Due to the nature of a healthcare facility, revenue streams mainly from insurance companies and government healthcare systems, like Medicaid and Medicare. That is why your medical billing team’s level of expertise and efficiency will directly correlate with your expected cash flow. Both having a team of professional experts and ensuring they are given the right tools is integral to maintaining the fiscal health of your facility.

Here are the top 3 most common causes we find for why even highly experienced accounts receivables teams are collecting less than they should.


They Don’t have Time


Probably the most common factor we’ve seen is lack of time. Your team needs to handle setting up new admissions, keeping up with current billing needs and addressing coverage issues that arise. At the same time, new claims keep coming in and take priority over old claims. Your staff is overworked, trying to stay afloat, and they don’t have the time to follow up on old, troublesome claims. It is a vicious cycle because the longer claims go uncollected, the harder it gets and more time it will take to recoup payment.


They Don’t Know How


Of course, you’ve made sure to invest in experienced medical billers, but here at LTC Collections we’ve found that a surprising number of receivables specialists may not understand all the codes and languages payers use in reference to a claim. There is a large, constantly growing number of codes to keep track of and the language used by the insurance companies can be hard to understand.

A common example we’ve seen when working on collecting aging AR for a client is a misunderstanding of the term “service not covered”. While this language can indicate a denied claim, it should not be immediately taken at face value. It is imperative to follow-up being that it can sometimes just mean that the claim was billed the wrong way.


They Don’t have the Right Tools


As we mentioned above, the coding and guidelines for medical billing are complex. This is where the right technology can be a tremendous asset. Investing in a robust software can automate the process and allow your team to stay on top of this information more efficiently.

Moreover, most long term care billing software on the market is not created to help employees track aging A/R. This can be problematic, causing uncollected receivables to fall lower and lower under the radar as they age.


Having a dedicated team of quality, efficient professionals can help you collect more, increasing your cash flow and improving your facility’s fiscal health. Here at LTC Consulting’s Collections department, we take on the recoupment of all aging AR and assist your team in solutionizing to get back on track.


The LTC Collections department services Skilled Nursing Facilities nationwide. Operated by a group of dedicated industry experts, we help clients reach new levels of profitability by efficiently collecting high ratios on outstanding AR receivable balances. The Collections department undertakes the recoupment process of outstanding Medicare, Medicaid and HMO/Managed Care receivable accounts for skilled nursing facilities. With unrivaled collection rates, our contingency-based and risk-free model can help your facility dramatically increase cash flow.



4 Proven Tips to Accept Referrals in Under 10 Minutes!

4 Proven Tips to Accept Referrals Quickly in a SNF


A common complaint among skilled nursing providers is how to fill empty beds. Vacant beds count as one of the the biggest expense at skilled nursing facilities. Many nursing homes are consistently at 70% – 80% capacity in what is an extremely competitive industry. Many facilities have access to many referrals, but they are just not acting fast enough. Since filling beds is the primary means to generate revenue, putting a proactive plan into place is of paramount importance.


Here are 4 Proven Tips to Accept Referrals and Ensure Profitable Admissions in Under 10 Minutes.


Tip #1: Managed Care Contracts

Make sure both the marketing and admissions teams have a clear understanding and written guide of the managed care payers that you are in network with. You should also be aware of each contract’s reimbursement rates and level criteria, what carveouts are needed, and if additional authorizations are needed for ancillary services.


Tip #2: Online Services

Invest in an accurate and efficient online software that you can use for eligibility checks across multiple payers. This will pay for itself in just a short while, when your team is no longer required to spend valuable time verifying payers through several different parties.


Tip #3: Proper Staffing

Employ a knowledgeable MDS Coordinator and Rehab Director. Staff members that can swiftly evaluate the amount of therapy needed and medication costs against the potential reimbursement when a referral comes in, can be an asset when it comes to determining profitable admissions.


Tip #4: Decide!

Once you have gathered all relevant information, it should be submitted immediately to an experienced decision maker who will consider all the variables to make the ultimate (and speedy) call on whether to accept or pass on a referral.


By taking the time now to put these simple steps into place, your staff will be able to accept profitable admissions swiftly and effectively in just minutes.


LTC Contracting is the complete solution for all managed care services and change of ownership needs. Established in 2016, our mission is, and has always been to effectively guide providers through all their contracting and HMO needs in full compliance with CMS regulations. This ranges from HMO Credentialing and Contracting, Case Management, Government Provider Enrollment, Licensure and Business Setup, and Behavioral Health Provider Services. Setting the bar in managed care guidance and results, LTC Contracting services clients nationwide with continuous growth and expansion, by cultivating strong relationships with insurers and government offices and utilizing our targeted market data to help lead our clients to financial success.

Inside Tips – 3 Trends the LTC Collections Team Looks For When Cleaning AR.

3 Trends Our Collections Experts Look at to Determine How to Clean up AR


[Spoiler alert – We’re letting some inside secrets slip in this article!]

At LTC Collections, we are generally called in to help once a skilled nursing facility’s receivables are really in a mess. Of course, that’s what we do best – get you the cash from old receivables that your team has deemed un-collectable. In this article we will explain how we determine where to focus our efforts when we receive a new account.

There can be many reasons why a claim was never followed up on: Perhaps the claim was denied, and your skilled nursing facility’s billing team didn’t get to fight the denial? Possibly there was a period, maybe due to change in staff, where some claims fell through the cracks? Or perhaps there were errors in how the claims were billed to begin with.

Our collections team sees many of the above scenarios daily, and more. In order to gain better insight of the full account, we begin by stepping back to see if we can pick up on any of the following over-all trends: timeline trends, resident trends and mis-posting of cash.

1. Timeline Trends


Timeline trends are much like they sound. The LTC Collections team takes an overall look at which time periods yielded stronger receivables and which were less profitable. From here, our experts analyze records from the time period to understand what variables may have led to the missing collectables and work to develop a strategy for recoupment.

2. Resident Trends


This trend is on a more clinical level: the collections analysts at LTC will delve directly into a specific patient case where there is a noticeably lower level of collected payer debt. Next, the LTC Collections team will analyze the data to see if they can pick up on anything from incorrect billing codes to mistakes in admissions documents within a specific resident’s records.

3. Mis-posting of Cash


While not exactly a trend, a common cause for missing on collectibles is mis-posting of cash. As part of our audit, our LTC Collections team will analyze the records to pick up on any billing mistakes and/or items that have been posted wrong.

Searching for these trends in your own aging AR can help you make some sense of it all so you can determine a plan of action when attacking the large (and somewhat overwhelming) project of collecting old receivables.

The LTC Collections department services Skilled Nursing Facilities nationwide. Operated by a group of dedicated industry experts, we help clients reach new levels of profitability by efficiently collecting high ratios on outstanding AR receivable balances.

Are Prior Authorizations for Skilled Nursing Really Necessary? What Covid19 Has Taught Us

Are Prior Authorizations for Skilled Nursing Really Necessary? What Covid19 Has Taught Us

Due to the Covid19 pandemic, many insurers waived the need for the initial prior authorizations for patients at skilled nursing facilities, which has us questioning, were these  auths really beneficial in the first place? Watch Steve Shain, COO of LTC Contracting, discuss prior authorizations for skilled nursing facilities.

Initial Prior Auths: Success or Excess?

Now what I want to talk about today is a change that was going on with the Prior Authorizations because of Covid19.

If you’re working in a Nursing facility you’re very familiar with this. Nursing facilities usually are taking patients from Hospitals and the insurance companies realized that the hospitals were overloaded with admissions and they were over capacity, and therefore in order to ease that transfer over from hospitals to nursing homes the insurance companies temporarily allowed for the waiver of Prior Authorizations.

So typically, you would need to get permission – clinical permission – from the Insurance company before treating a patient in a nursing home, taking them from a hospital to do so. But during Covid-19, the Insurance companies waived that and they let you just take the patient as long as you notify them that the patient was now in your facility.

So as of June 1st, most insurance companies stopped that waiver and right now are back to regular programming. There are some insurance companies, such as Cigna, which are keeping this rolling thru July, which is really impressive and really nice of them. But for the most part everything is really getting cut just now, June 1st.

And it is very understandable why Insurance Companies have these policies for Prior Authorization in place. Because, Number 1: they want to make sure their members are getting the right level of care and the right type of care, and therefore they want to make sure that they can monitor and help make that decision , where the patients best care would be given. And, Number 2: of course to keep their costs down in order to make sure that this is the most cost effective location for their member.

But I wonder, and this is for all the insurance company reps that may be watching this, I wonder if you look at the data in 3,4,5 months from now and look back and see how many times during this period of time -whether it was March, April, May- that you did have members that were, even though the hospital thought it was the right level of care , even though their family and they felt it was the right level of care, but for some reason they were placed in the wrong level of care. And how many of these were really not cost-effective admissions?

I wonder, because on the other side of the coin you have so much extra paperwork and so much cost on the Insurance company side for case managers. And the pressure that goes along with it on the hospital and skilled nursing facility side to get those authorizations in place quick enough in order to make sure the member has a smooth transition over to the next level of care.

I wonder if all that is really worth it, but I’m curious to see. And hopefully with time we will find out those answers.

Thank you so much for watching!


Steve Shain is the Chief Operating Officer of LTC Contracting.

LTC Contracting guides providers through licensure and business setup procedures and ensures compliance with all regulations, whether the providers are opening new organizations or adding new service lines to their existing businesses. LTC Contracting’s services also include getting providers credentialed and on the Managed Care Organizations’ (MCOs’) networks.

COVID19: CMS Waiver 1135 – Here’s what you need to know

Staying Alive and CMS Waiver 1135

A COVID-19 Managed Care Update

I hope wherever you are, you are staying safe, acting smart, and keeping strong throughout these very challenging times.

I’m going to take a tip from everybody on this platform , that is trying to help others out with information as much as possible and I’d like to give you a quick update on how Managed Care is being affected within skilled nursing facilities and the healthcare environment.

But first we must talk about Medicare and understand what changes have been put in place by CMS.

There is the 1135 waiver which was put in place to ease some of the restrictions regarding how skilled nursing facilities can treat Medicare members. For the most part the 1135 waiver allows the 3 day Qualifying Hospital Stay to go away, as well as the 60 day wellness break that’s in between benefit periods for a Medicare 100 day benefit period to also be looked aside , as long as – and this is important – as long as the resident in your facility qualifies or falls in to the category of someone who was affected by the Coronavirus. So, it cannot just be anybody, but it must be somebody that was actually affected. It does not have to be directly but can even be indirectly affected by the virus is why you are looking to continue their coverage.

Another thing that is important , because I was asked by a facility yesterday, is that if you have a Medicare member that is no longer skilled and really can be discharged or moved to a lower level payer, the 1135 waiver will not allow them to remain covered by Medicare it is only for those that have a skilled need.

And finally, there are other things that the waiver allows for regarding PDPM assessments as well as a few other things, but I would like to simplify it and just discuss this.

In regards to Managed Care we’ve spoken to many Insurance companies yesterday, and for the most part firstly understand that most of the insurers do not require a 3 day qualifying hospital stay for coverage so therefore that portion of the waiver is not really relevant.

It is important to know that as of now the pre-certification and extension process in order to maintain authorizations is staying as it is. Something to keep in mind is that there will be more likelihood of residents that will admitting from home vs. from the hospital.

Typically, the hospital will have a lot of the medical records to submit, so when you’re getting a pre-certification now from the insurance companies make sure to submit whatever medical records the resident does have. It could be their doctors note, it could be any other medical records that justify the need for them to be in a facility. And the insurance company will review that and take that into consideration.

Obviously if there is any extenuating circumstance or something that needs to be addressed because of the current situation, they will look at that and make a case by case decision.

One more request that Insurance companies had, is that if any of your residents do test positive for Corona virus, to immediately inform the insurers of any of their members that are in the facility as well. They need to be aware of this, they need to be notified and they to more this up the chain to whoever they need to notify. So please be vigilant about this, and if you have anything else to add in regard to this that i may have not mentioned, please mention it in the comments.

And in general, just like we are doing here, trying to give helpful information for those that we can help please do the same for your field and your areas of expertise. If you have any information that can help other people, now’s a great time to do it.


Steve Shain is the Chief Operating Officer of LTC Contracting.

LTC Contracting guides providers through licensure and business setup procedures and ensures compliance with all regulations, whether the providers are opening new organizations or adding new service lines to their existing businesses. LTC’s services also include getting providers credentialed and on the Managed Care Organizations’ (MCOs’) networks.

3 Common Healthcare Admissions Mistakes


These 3 Common Healthcare Admissions Mistakes May Be Occurring Daily in Your Skilled Nursing Facility:


1. “Skilled” Patients Being Admitted as “Custodial” Following a Hospital Stay


When the hospital needs to authorize the return of a previous resident of your facility, you may feel that you should do whatever it takes to allow the patient to return. After all, your facility has been his/her home for the past few months (or years) and it is where he/she has been most comfortable. However, it’s imperative to check your facility’s HMO contract prior to admitting anyone, even a long-term resident of your facility, to ensure that it includes a “skilled” benefit.

If the patient is classified as needing “skilled” treatment, you cannot admit him/her on a Custodial plan, regardless of whether you may plan to provide the “skilled” level of treatment.

As per CMS regulations, billing someone under a level different than what they are actually receiving (whether higher or lower) is illegal. If you don’t have the “skilled” contract, you will have to refuse the admission.


2. Rejecting Admissions Unnecessarily: High-Cost Admissions Can Still be Profitable


You want to admit as many referrals as you can and fill your facility’s beds; but many times, the projected expenses of the patient’s care seem to outweigh your room and board rate. You may feel that it will be more profitable to deny an admission based on high cost needs, be it  expensive drugs or wound therapy.

However, it’s important to do due diligence before denying any admission. Research each case and never take the numbers at face value. Are there carve-outs you can utilize to offset some of the high expenses? Does your contract with this specific payer allow for any exclusions for high-cost drugs or lab? Pre-negotiating good contracts with each payer that include the common carve-outs and exclusions will allow you to accept even high-expense patients.


3. Mistaking an HMO Community Medicaid Admission with an HMO MLTSS Admission (Even if they are both Long Term)


Be on the lookout for Community Medicaid admissions, as you’ll need to be prepared to stay on top of many aspects of the patient’s billing process. Many times, a facility will automatically admit a Medicaid member and make the mistake of assuming they can easily obtain an authorization, as with an MLTSS member. The authorization process for Community Medicaid is a bit more time consuming .

You’ll also need to make sure your facility is contracted properly with the payer for Community Medicaid as opposed to LTC Medicaid. And of course, make sure you have a plan in action to move the patient to a Long-Term product so there will be no lapse in coverage.


A substantial percentage of admission mistakes are potentially avoidable. Being aware of these small details can go a long way in increasing your daily census and overall reimbursement.


LTC Contracting’s specialists are trained to assist your newly acquired SNF in obtaining and negotiating a favorable deal with the insurance company, whether it be a Commercial, Managed Medicare, or Managed Medicaid plan. For a professional review of the Medicaid/Medicare billing options for your newly acquired SNF and for any other related information, contact us at LTC.  

What you need to know about the 02/01/2020 NY MLTC changes for Skilled Nursing Facilities.

Hey Everyone!

I want to let you know that we are so proud of our New York skilled nursing facilities! Amazing what you guys pulled off!

If everybody is not familiar, in New York there’s a safety rule – “If you see something say something” – and that’s exactly what New Yorkers did in skilled nursing facilities.

They said that it doesn’t make sense for MLTC’s to be required to cover long-term patients in a skilled nursing facility, so they pushed back. The skilled nursing facilities pushed back, the associations in New York pushed back, and they got what they wanted.

As of February 1st, there is no longer going to be a requirement for MLTC’s to cover a patient that is long-term in a skilled nursing facility in New York.

How is that going to affect you? In three ways.

Before I get to that, I want to give a quick thank you to Jacob Friedman for giving me this information so clearly and understanding how it affects every facility in New York.

So the 3 scenarios are if somebody is already in a skilled nursing facility for 90 days, that is enough determination that they’re going to be long term, and therefore as of February 1 they will move to Medicaid fee-for-service.

So, if you’re familiar with epaces, that means they’ll be moving from an N to an NH on New York Medicaid.

If somebody is in a skilled nursing facility under a MLTC, but have not been there yet for 90 days, they will remain under the MLTC for the 90 day period and then move over to Medicaid fee-for-service at that point.

The last category is someone who is applying for long-term Medicaid. Once they’re determined to be eligible for Medicaid and determined that they are long-term, will move directly onto Medicaid fee-for-service not even getting enrolled in a MLTC at all.

So this is a major change for New York and it’s really exciting!

And for my Illinois friends, yes, you guys pulled off months ago that the managed Medicaid do not require the authorizations, but you’re still working with the managed Medicaid.

It’s exciting to see in New York that the managed Medicaid for long-term skilled nursing facility is completely going away!

So, if I gave an example, I would say that New York is kinda like quitting smoking cold turkey while Illinois is still vaping. You guys are still kind of hooked but hopefully you’ll get there and hopefully all states will get there soon. And as the industry shifts of course everyone is shifting along with that.

If anybody has any questions for New York facilities about how this is going affect your facility and how this is going to affect your case management, your staff, and your contracting, feel free to reach out to me.

I’d be happy to answer your questions and help out.

Have a great day!

Steve Shain

LTC Contacting
Contract Smoothly!
Contracting • Case Management • CHOW’s

How a SNF Change of Ownership Affects Medicare/Medicaid Billing

Image by <a href="">Capri23auto</a> from <a href="">Pixabay</a>How a SNF Change of Ownership Affects Medicare/Medicaid Billing


You recently acquired a skilled nursing home where rehab and/or nursing services are provided. Here’s what you need to know about how this will affect your reimbursement with Medicare and Medicaid during Change of Ownership (CHOW).

Nursing homes that recently changed SNF management should be aware that it will take some time following the acquisition before becoming certified and approved to begin billing for the services it provides. While the delay can prove quite problematic for cash flow, certain states may allow a viable solution that a new skilled nursing facility owner should be informed about.

The answer for you may be including a provision in the operations transfer agreement that allows the provider to bill and get reimbursed through the seller in the crucial first few months of operation.

Does Your State Allow Billing through the Seller?

Prior to negotiating a contract with the seller about billing facilitation, it’s important to understand that rates often change and the varying state laws about Medicare and Medicaid billing can be complicated.

LTC Contracting provides the following summary highlighting the different billing allowances in the 9 key states we deal with.

  • New York allows a SNF to bill through the seller.
  • New Jersey does allow billing through the seller for fee-for-service, however, most of the MLTSS MCOs will only provide a new contract once you are certified with Medicaid.
  • Maryland, Connecticut and Pennsylvania do not allow billing through the seller.
  • Massachusetts does not allow seller billing, nor does it allow you to apply for a Medicare number until you are approved.
  • Georgia requires you to be approved prior to applying for a Medicare billing number, but you can bill through the seller.
  • Wisconsin does not allow billing through the seller; however, you can bill Medicare before Medicaid is approved and then tie it in once you have been certified.
  • Florida does not allow billing through the seller and approval is a long process, often up to 9 months. Moreover, the HMO utilizes its own agreement based on rate changes that generally go into effect after a sale, prompting many new SNF owners to forgo the seller billing process and swallow losses to circumvent the snags involved in the aftermath of lower rate adjustments.

LTC Contracting’s specialists are trained to assist your newly acquired SNF in obtaining and negotiating a favorable deal with the insurance company, whether it be a Commercial, Managed Medicare, or Managed Medicaid plan. Constantly keeping abreast of changing state laws, we are experienced in helping you navigate and procure a reasonable contract with the seller so that your nursing home will benefit from the best possible billing scenario during the Medicaid and Medicare certification wait-time.

For a professional review of the Medicaid/Medicare billing options for your newly acquired SNF and for any other related information, contact us at LTC.