Welcome to the HealthPRO Heritage Blog

An Exclusive Interview with HealthPRO Heritage’s Clinical Reimbursement Expert, Teresa Toth

Join us as we deep dive into a decision Ohio providers need to make with our Clinical Reimbursement Expert, Teresa Toth, RN, DNS-CT, RAC-CTA, where we address the pressing question on everyone's minds regarding case mix – to freeze or float? In the dynamic landscape of healthcare reimbursement strategies, making informed decisions is paramount. Let's delve into the conversation with Teresa and discover some valuable insights.

Our readers are eager to understand this conundrum: whether to freeze the current case mix for Medicaid or let it float. Can you shed some light on this?

Teresa Toth: Absolutely, I'd be happy to help. The decision to freeze or float your clinical reimbursement strategy isn't a one-size-fits-all scenario. It heavily depends on the unique circumstances of each healthcare center.

Could you elaborate a bit more on how these circumstances play a role in the decision-making process?

Teresa Toth: Of course. If a healthcare center is performing at or above the state average, leaning towards a freeze might be a wise choice. This allows them to maintain their current course while focusing their efforts on Quality Measures (QMs), census, and staffing to earn Quality Incentive Program (QIP) points.

What about centers that are struggling or performing below the state average?

Teresa Toth: For centers that find themselves below the state average, the decision becomes a bit more nuanced. If they have been actively working on improving their Case Mix Index (CMI) and are seeing positive results, they might want to continue calculating the CMI. On the other hand, if CMI is a challenge, freezing the current strategy and redirecting efforts towards QMs for the QIP program could be a strategic move – particularly if there's potential for qualification. In such cases, it's important to recognize that center resources might be limited, so focusing on one area might be more feasible and effective.

You mentioned the changing landscape of the Quality Incentive Program. Can you provide some insights into how this impacts the decision-making process?

Teresa Toth: Certainly. In Ohio, the performance point cut-off for the bottom 25th percentile among centers is dynamic, shifting annually as all centers improve. Moreover, with the recent introduction of semiannual changes to QIP payments, this landscape becomes even more fluid. Centers need to keep a close eye on these shifts and adapt their strategies accordingly.

Teresa, you brought up a key aspect – financial considerations. How does the financial aspect influence this decision?

Teresa Toth: Financial considerations play a pivotal role. If a center is comfortable with its current reimbursement rate and can operate smoothly, freezing the strategy might be prudent. This approach enables the center to plan for the next two years based on the current CMI and potential payments. However, centers must be aware that freezing could introduce additional work, such as dealing with the Optional State Assessment (OSA). It's crucial to assess the capacity of the MDS Coordinator and the team responsible for MDS, especially in terms of managing the potential extra workload.

And lastly, how do team dynamics and workforce stability factor into this decision?

Teresa Toth: An astute question. If a center is already struggling or has limited resources, introducing additional assessments due to regulatory requirements could strain the team. Losing valuable team members due to increased workload is a real concern. Therefore, the center must evaluate their current situation and assess whether they're equipped to handle the additional demands that may arise from a specific reimbursement strategy.

Teresa, your insights are invaluable. Thank you for providing such clarity on this complex matter. Before we wrap up, is there any final advice you'd like to share with our readers?

Teresa Toth: I'd like to emphasize that there's no one-size-fits-all answer. It's vital for healthcare centers to deeply analyze their current position, resources, team capabilities, and financial stability before making a decision. Seeking input from the business office and financial experts is crucial. Ultimately, the decision should align with the center's long-term goals and ability to thrive in the evolving healthcare landscape.

We trust that this enlightening discussion with Teresa Toth has equipped you with the insights you were looking for. It's crucial to bear in mind that in the realm of clinical reimbursement, well-informed choices form the bedrock of achievement. If further assistance is needed, don't hesitate to reach out to our dedicated Clinical Strategies team. Your success remains our priority.