Case Study

PAC Case study: How one SNF unlocked $472K in Medicaid reimbursement

    While increased volumes typically unlock additional revenue, a carefully chosen specialty can also drive increased reimbursement by capitalizing on the idiosyncrasies of a provider’s payment structures.

    Continue reading to learn how one SNF capitalized on a provider's payment structure to unearth additional Medicaid reimbursement. For more tactics to build and support specialty lines, download our research report excerpt: 10 Tactics to Ensure Specialty Return on Investment, Part 1.

    Download the research report






    In Pennsylvania, a 0.01 increase in a skilled nursing facility’s case mix index (CMI) correlates with an increase of $1.38 per patient per day in Pennsylvania Medicaid reimbursement.

    To leverage that payment opportunity, Susquehanna Health Skilled Nursing and Rehabilitation Center opted to specialize in ventilator weaning. Vent-weaning patients are measurably more complex than the general skilled nursing population and an influx of that patient type increased the facility’s CMI from 1.10 to 1.18.




    Blog post: One way to recapture lost volumes




    Effect of Facility CMI on Pennsylvania Medicaid Rates


    As a result of a higher CMI, Susquehanna earned an additional $472,000 across a single year. They are also eligible for a $35,000 bonus payment if the facility has at least 10 ventilated Medicaid patients on each of Medicaid’s randomly chosen audit days.


    Susquehanna Health Skilled Nursing and Rehabilitation Center’s
    vent-weaning specialty line development



    Roughly two-thirds of the facility’s ventilator-weaning patients are Medicaid beneficiaries, but the ventilator-weaning program’s results are not limited to Medicaid patients. Susquehanna has successfully negotiated with other payers, including Medicare Advantage and commercial insurers, for higher carve-out rates for ventilator-weaning patients.

    The opportunity to drive reimbursement by increasing a facility’s acuity level is not limited to Pennsylvania. Most states have variations on similar payment structures. Each post-acute provider should uncover and understand the reimbursement opportunities available in their local market and evaluate their programs to take advantage of these payment rules.



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    Additional Medicaid Reimbursement

    For more tactics to build and support specialty lines, download our research report excerpt: 10 Tactics to Ensure Specialty Return on Investment, Part 1.

    Download the research report



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