How to Choose a Qualified Medicare Reimbursement Partner

The significance of the cost report, its complex nature, and the evolving regulatory landscape has created an industry-wide trend. Hospital providers seek not only to outsource their cost report preparation and all supplemental payments to outside expertise, they also want to consolidate their reimbursement activities with one firm.

Consider these key attributes to help you select the right partner for your Medicare reimbursement needs:

  • Experience and expertise
  • National presence
  • End-to-end solution
  • Access to a deep bench
  • Ability to meet the challenges of change
  • Fee structure

Experience and Expertise

Begin wisely by choosing a partner with a proven track record.

Given reimbursement complexities, put consultants with decades of experience and hundreds of clients—that span the entire country, not just your region—at the top of your list.

Consider the size of the team, which can indicate if a firm has an established and comprehensive practice. Also consider their collective years of experience and the size of their legacy client base. Also note their audit acceptance rate if they provide an audit support function.

Provider or Auditor Experience

Experience isn’t just about quantity—quality is easily as crucial.

Many Medicare reimbursement consultants have experience as providers or Medicare administrative contractor (MAC) auditors, granting them a wider perspective to understand your hospital’s unique situation.

In addition, consider more narrow specifications such as expertise at the state and federal levels.

National Presence

A partner with a nationwide presence can leverage their deep knowledge of a national marketplace as well as local competitive markets.

As they work with various clients and learn from different experiences, consultants continually expand their expertise and evolve their processes so they can provide more comprehensive and customized solutions.

End-to-End Solution

Engaging a partner who deeply understands the cost report and specializes in supplemental payments is essential to uncover opportunity.

Critical components of a hospital’s reimbursement program should include data analysis to identify trends, flaws, and other areas of concern.

Full visibility can only be accomplished with one firm completing the cost report and all supplemental payment support.

When data reporting is siloed, optimization and compliance gaps widen and missed opportunities increase. Additionally, outsourcing reimbursement activities to one partner with an end-to-end solution brings costs down and may reduce tripping points that can occur with piecemeal processes.

An ideal end-to-end reimbursement solution should include:

Audit Support

Not all firms include this, so in the event of an audit you want to know that the firm you engaged will stand behind their work and support you.

Look for a firm that has a good relationship with your MAC and deep familiarity with programs specific to your state.

It’s also a good sign if the team supporting the audit also completed the project. You might also consider the tenure of the team.

Access to a Deep Bench

Addressing your organization’s reimbursement needs is vital, but you likely face concerns and have complex needs that go beyond this core function. Additionally, most organizations contend with limited resources and expanding demands.

When considering an external partner, do they have access to extensive resources and tools to address all emerging needs—both now and in the future?

Determine if they can provide value-added support in areas such:

As your needs change, your partner should introduce the necessary resources to serve your organization, guiding you to make smart, informed business decisions and find innovative financial management solutions that help drive growth and reduce risk.

Ability to Meet the Challenges of Change

The accelerating pace of change, especially in provider reimbursement, challenges providers. More and more, providers need to keep up with the ever-changing and sometimes cumbersome regulatory landscape from shifting timelines to significant legislation changes.

Reimbursement partners should focus on keeping up to date with the latest rules, regulations, deadlines, and state programs to ensure compliance of all data compiled for the cost report and supplemental payments.

The right consultant will work to put knowledge in your hands. As a provider, your partnership should grant you access to diverse resources so you fully understand the reimbursement process. Is your partner providing opportunities for education and access to meaningful and industry leading education forums?

While webinars, blogs, and newsletters can help provide resources, the best consultants will also offer detailed analysis and custom modeling for your hospital.

Workforce Challenges

Hospital reimbursement staff bandwidth constraints are present and continue to make full operational efficiency difficult.

Additionally, as career-long reimbursement professionals exit the workforce, it creates a knowledge vacuum in organizations. Replacing staff with equal talent proves insurmountable.

A partner should guide you to the information and resources you need now and provide strategies for the changes to come.

They should also provide a customizable, comprehensive portfolio of enterprise-wide solutions that can augment your current in-house resources and reimbursement needs.

Fee Structure

The cost of an engagement tends to dominate the decision of many hospitals in search of the best partner. But you might consider other factors outside of the bottom-line cost as a good steward for your organization, such as:

  • Assess key differences between vendors in the deliverable. Low-cost providers typically deliver a basic service, where higher-cost providers may provide additional value. If you can’t determine the value of the additional services, ask the firm to detail how the additional costs drive additional value.
  • Assess risk levels. Some firms deliver lower cost services but transfer the risk of their work to the hospital. This often occurs in Medicare DSH services, where the firm provides Medicaid matching services, but leaves decisions related to which patients to include in the DSH calculation to the provider. In these situations, is the increased risk worth the savings?
  • Assess experience level. Firms with less experience often charge lower fees to gain market share. Weigh the risk of inexperience when evaluating a trusted partner.

Whatever the fee structure, it’s always important to understand the scope of services from potential service providers before selecting the service proposal.

Additional Questions to Consider

Due diligence is a term you hear most often in the context of a merger or acquisition, but it’s a concept that’s equally relevant when choosing an external reimbursement partner.

Given the complexity of provider reimbursement, it’s critical to choose carefully and confidently.

This includes asking tough questions and evaluating key attributes, such as, does the partner:

  • Have staff with a long tenure who have deep knowledge of the cost report, possess provider or auditor experience, and a national footprint?
  • Lower costs by assigning inexperienced staff to the engagement?
  • Have a thorough, documented approach with a high audit acceptance rate?
  • Have the capabilities to complete the cost report and all supplemental payments, thereby allowing unsiloed access to data which can provide visibility into areas of opportunity?
  • Have access to additional resources and a bench of health care expertise that can assist with your emerging needs?
  • Provide access to meaningful and industry leading educational forums that keep you abreast of the latest reimbursement landscape?
  • Provide you with a customizable, comprehensive portfolio of enterprise-wide solutions that can augment your current in-house resources and reimbursement needs, if needed?

The more detailed the due diligence you perform on a partner, the less risk you might find in an organization down the road—and the greater the chance to successfully attain your rightful reimbursement.

Getting your reimbursement doesn’t need to be complicated, especially when you know what you want in a partner. Reference these attributes to help secure the right partnership for your organization.

We’re Here to Help

To learn more about the benefits of outsourcing reimbursement needs or navigating the Medicare reimbursement process, contact your Moss Adams professional.

You can also learn more about our Health Care Practice and find related information.

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