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White Papers & Articles

Marc Zimmet: The Inequity of Medicare Copayment

October 20, 2022

THE INEQUITY OF MEDICARE COPAYMENT is a structural deficiency in the SNF revenue-cycle unrelated to the Patient Driven Payment Model, which establishes patient-specific per diem rates across a Medicare Part A Benefit Period (up to 100 days). Medicare pays providers 100% of the PDPM rate for days 1 – 20, then applies a $200/day coinsurance reduction to the remaining (up to) 80 days. Beneficiaries without a supplemental Medigap policy must pay coinsurance out-of- pocket, which providers are required to pursue.

“Dual-eligible” beneficiaries are enrolled in both Medicare and Medicaid. Medicare Part A is the “primary” payer for qualifying SNF short-term care; Medicaid, as “secondary” insurer, is charged the $200/day coinsurance (Medicaid assumes primary-payer status after the Medicare benefit is exhausted). Federal Medicare policy is consistent across the nation; Medicaid is administered at the state level, with payment rules so variable they perversely distort the Medicare benefit Medicaid is designed to support.

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Filed Under: White Papers & Articles

Marc Zimmet Responds To The 2023 SNF PPS Proposed Rule

June 9, 2022

Zimmet Healthcare Services Group, LLC (“ZHSG”) respectfully sets forth this response to the 2023 SNF PPS Proposed Rule (CMS-1765-5). This submission was prepared independently by ZHSG, without third-party participation or sponsorship. Perspectives are balanced across ZHSG’s multi-disciplinary experience with SNF reimbursement, market trends, and operating challenges. Claim analysis was conducted by our affiliate company Z-CORE Analytics, LLC (“CORE”); utilization from 3,000+ SNFs for services through April 2022 inform our remarks on recalibration and are specific in scope to the CMS rulemaking process.

Filed Under: White Papers & Articles

Marc Zimmet: The 2023 SNF PPS Recalibration Adjustment

April 18, 2022

The Patient Driven Payment Model is a rare bright spot in Skilled Nursing’s dreary reimbursement landscape, but storm clouds are on the horizon. CMS has proposed recalibrating SNF rates to correct for unintentional spending relative to the RUG system it replaced. The agency refers to this reduction as a “Party” but in the context of a post-pandemic operating environment, the proposal reads more like a “Reimbursement Parody” to me…

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Filed Under: White Papers & Articles

Marc Zimmet: The Medicaid Rate Construction Infrastructure Crisis

March 8, 2022

The codependent Medicare/Medicaid duopsony can no longer balance the SNF financial equation. Medicare Advantage, Alternative Payment Models, and ill-conceived experiments with Managed Medicaid LTC created structural deficiencies the current economic model was not designed to absorb. 

Skilled Nursing was saved from pandemic distress by emergency federal funding. Now, in the face of comprehensive reform, policymakers must fortify the industry’s reimbursement foundation. Reliable data is essential for success; without it, a decades old incongruity threatens to destabilize the entire healthcare continuum. 

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Filed Under: White Papers & Articles

Medicare Advantage Disenrollment Trends in New York State Skilled Nursing Facilities

October 29, 2021

Medicare Advantage (MA) is a voluntary, alternative health insurance option available to Medicare eligible beneficiaries. MA is offered by a growing number of insurance companies and enrollment is expanding rapidly; in fact, MA coverage outpaces the “original” or fee-for-service (FFS) Medicare program in many markets. The “private option” offers cost savings and supplemental benefits in exchange for limitations to patients, specific to provider choice. While this cost/benefit dynamic clearly appeals to enrollees residing the community, the model generally does not create the same balance for residents of long-term care facilities. As a result, disenrollment from (or changes to specialized) MA plans is far more common in the institutional setting than the population at large.

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Filed Under: White Papers & Articles

Marc Zimmet: The CORE Reporter, October 2021

October 11, 2021

CORE analyzes current Medicare and Medicare Advantage claims to identify reimbursement opportunities and measure a facility’s value-proposition against its peer group. As of October 1, CORE tracks Medicare performance through August 2021, while the LDS does not extend past March. CORE also delivers the same standard LDS tools, but we believe providers should not be forced to pay for access to public data; we simply include the functionality as a handy value-added service.

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Filed Under: White Papers & Articles

Marc Zimmet: Medicare Advantage & SNF Reimbursement

October 1, 2021

The Rime of the New World Mariner:

It is a New World Mariner,
And he stoppeth wounded knee,
With long grey beard and rehab needs, Now wherefore stopp’st thou he?

Data, data everywhere,
Still all our rates did shrink, Data, data everywhere,
Yet all of it doth stink.

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Filed Under: White Papers & Articles

Survival of the SNFittest

December 15, 2020

A generation ago, SNFs were on the precipice of an epigenetic shift that would carry them beyond “subacute” care. They would offer managed care organizations a cost-effective alternative to hospitalizations. Facilities were renamed; more “D/B/As” were filed in 2001 than in all previous years combined. “Nursing Homes” became “Health & Rehabilitation Centers.” SNFs would create and lead Integrated Delivery Systems to the promised land known as “Healthcare Reform.” Alas, it seems that insurance companies, not to mention nature, have rules. No matter how far the SNF model of care progresses, people still struggle to see beyond their outdated image of “nursing homes.” A comparative search on Google Trends distills the essence of public perception. What will it take for skilled nursing facilities to finally evolve?

Read more below in Marc Zimmet’s “On the Origin of SPEOCCUPANCIES”

Origins

Filed Under: White Papers & Articles

Happy ThankSNFing!

November 26, 2020

Thanksgiving is a time for gratitude and appreciation. But for those who endured the darkest days of this pandemic, it’s an opportunity to process, in groups of no more than 10 people, hardships that were unthinkable way back in the age known as BCE (Before the COVID Era). Yet there is good reason for optimism with a vaccine just weeks away, so let’s take a moment to reflect on what SNF operators can be thankful for this year.

Read Marc Zimmet’s “Happy ThankSNFing” message below:

 

Happy ThankSNFing!

Filed Under: White Papers & Articles

THE COVID-EFFECT: A Comparative Analysis of April 2020 Medicare SNF Claims

June 9, 2020

COVID distribution reporting is subject to extreme bias for a host of reasons – first and foremost, the virus is selectively more threatening to the health-compromised elderly – a cohort that disproportionately resides in institutional settings. Statistically, introducing one person infected with the coronavirus to a nursing facility would produce outcomes that are non-comparable to introducing that same catalyst into Central Park on a warm spring day.

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Filed Under: White Papers & Articles

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