Managed Care- How Have You Fared?

Transcription

1 Managed Care- How Have You Fared? Janine Mangione, CPA, Partner / jmangione@bonadio.com Kelley DeMonte, CPA, Principal / kdemonte@bonadio.com Agenda Managed Care Background Value Based Payment Model What s it Going To Look Like? Managed Care What are we seeing? Strategic Positioning Questions to be Asked and Answered by Your Organization Considerations of IPA s 22 1

2 Polling Question How well versed are you in managed care? A) I could teach this session B) For the most part I get it, but it s hard to keep up C) I am well versed, but still have a hard time getting paid D) Just hoping it will go away 33 Managed Care Background Implemented in Upstate NY July 1, We are currently in a transition period through 2017 Most providers have contracts with plans at a rate at or above Medicaid benchmark rate As part of the state budget, managed care organizations will still be required to reimburse nursing homes at the Medicaid benchmark rate through December 31,

3 Managed Care Background By 2019, 80-90% of total managed care payments to the PPS and providers must be made via at least Level 1 (upside shared Savings) value based payment (VBP) Part of DSRIP Initiative Moves Medicaid payment from current fee-forservice system to alternative payment arrangements (i.e. bundling, risk sharing, capitation) 55 Value Based Payment Levels Level 0 VBP FFS w/ Quality Bonuses* Level 1 VBP FFS w/ Upside Shared Savings Level 2 VBP FFS w/ Risk Sharing (Upside, Some Downside) Level 3 VBP Full PMPM Capitation & Risk (Full Upside and Downside Risk) * The State has agreed to count these types of arrangements between MLTC plans and providers as Level 1. They are Level 0 for mainstream plans and providers. 66 3

4 Value Based Payment How does this impact long-term care providers? Many homes are not positioned to take the risk required with VBP models Homes that are capable of reporting quality statistics stand a chance of benefiting from the upside shared savings Expected that most homes will only be able to accept and move to Level 1 VBP arrangements 77 Value Based Payment Medicare SNF VBP beginning in FY percent withhold of Part A payments with an opportunity to earn back based on certain quality metrics Re-hospitalization rate Level of improvement 88 4

5 Value Based Payment What will these Medicaid VBP contracts look like? Pilots? Plans are in the early stages of developing these contracts 99 Polling Question How many managed care plans do you currently have contracts with? A) Zero B) 1-2 C) 3-5 D) more than

6 Managed Care What are we seeing? Plans behaving different Plans less eager to contract with long term care providers Plans not willing to negotiate above benchmark Plans attempting to amend contracts Plans are finding that the payment model that they are receiving from NYS is unsustainable Under the current payment model, plans will be tempted to contract with providers that have the lowest cost Polling Question Has a plan attempted to terminate a contract with you? A) Yes B) No C) I can t get a plan to even contract with me

7 Managed Care What are we seeing? Contract language is changing NAMI The right to amend contracts Contract terms Definition of patient co-pay or customer expense More specifications related to revenue codes, and electronic claim submissions Managed Care What are we seeing? Net Available Monthly Income (NAMI) As part of the NH transition policy, the responsibility to collect NAMI amounts is being assumed by the plans. Plans may delegate the collection of NAMI to the NH, but this must be expressly agreed to by the provider in the participating provider contract. Monthly premium payments to the plans will reflect an offset for NAMI amounts. If the plan retains responsibility to collect NAMI, it should pay the facility the full contract rate multiplied by the days of care provided. If the plan delegates NAMI collection to the facility, the NAMI amount should be deducted from payments to the NH for those time periods during which the NAMI is collected by the NH

8 Strategic Positioning Questions to be Asked and Answered by Your Organization With the Department of Health (DOH) now driving the bus, healthcare service providers with reduced administrative costs will be one of the sources of achieving efficiency. What is the provider doing proactively to address its administrative cost efficiency and, more broadly, the State s desire for mergers, affiliations, and shared service organizations to achieve a more efficient healthcare delivery system? Evaluate the merits of joining a Regional IPA and/or MSO. If you don t know what those acronyms mean, consider yourself to be in trouble! Strategic Positioning Questions to be Asked and Answered by Your Organization The following areas are of highest priority in evaluating the question above: a) Partnering/merger/affiliation with other service providers b) Participation in regional provider networks c) More sophisticated cost accounting and electronic records for all program components d) Restructuring your billing and accounts receivables systems to accommodate revised contract payment methodologies (e.g. incentive payments for achieving performance goals, P4P) e) Incremental cost structures on administrative infrastructure (technology, compliance, etc.) will be a significant challenge in assessing your organization s future services and structure. Ask yourself the question, are we sophisticated enough to survive in a VBP reimbursement environment that demands high service quality and desirable outcomes?

9 Polling Question Is your organization currently part of an IPA? A) Yes B) No C) In the process of forming one SNF Managed Care 9

10 Who does Medicare or Medicaid pay? Who does provider bill? Providers available Permission needed for services? Policy incentive to give too much/little care? What package of services is available? Fee-for-Service (FFS) Pays each provider for each service rendered Provider bills Medicare or Medicaid directly Any provider who accepts the insurance Sometimes. Medicaid need approval for PCS, CDPAP, etc. but not all medical care Incentive to bill for unnecessary care offset when authorization is needed for services All Medicare and Medicaid services Managed Care Pays a flat monthly fee (capitation) to insurance plan Bills the Managed Care plan which pays from a monthly capitation rate from Medicare or Medicaid Only providers in the insurance plan s network Often. Plan may require authorization to see specialists or for many services. May not go out of network. Plan has incentive to DENY services and keep part of capitation rate for profit Package of services may be partial (MLTC) or full (PACE = all Medicare and Medicaid services 19 Pre-Billing 10

11 21 Rates Medicare Advantage Negotiated per diem rates or Medicare rate Commercial Plans Negotiated rates o Pay lesser of daily rate or billed UCC rate Medicaid Managed Care Rate 3 year current FFS (benchmark) rate or negotiated Must be increased if rate falls below current benchmark rate If previously negotiated rate: pay benchmark during transition unless other arrangement is agreed to 22 11

12 Bed Hold Methodology Medicaid Managed Care Bed hold methodology unless otherwise negotiated, MCO required to follow current Federal/State Medicaid bed hold regulations (CFR and 10YCRR and 18NYCRR 505.9) prior authorization may be required Reimbursement Limitations LOA temporary hospitalization / health care professional therapeutic LOA non-hospitalization / health care professional therapeutic 0 Hospital bed hold payments eliminated effective 4/1/17 95% Not to exceed 10 days in any 12 month period Must have been resident for at least 30 days and unit to which recipient will return has a vacancy of no more than 5% If plans not paying contact Vallencia Lloyd (Mainstream) vallencia.lloyd@health.ny.gov OR Mark Kissinger (MLTC) mark.kissinger@health.ny.gov 23 Billing / Payment Cycle Medicare Advantage and Commercial Billing cycle monthly Payor specific payment cycle and retrieval options Medicaid Managed Care Billing Cycle at least every 2 weeks or twice a month remittance o Not generally mentioned in provider/billing manuals don t make assumptions o Does billing department needs to change current process? Payor specific payment cycle and remittance retrieval options Medicaid Weekly payment cycle 24 12

13 Enrollment Medicare Advantage and Commercial plans Enrollment changes not limited to open enrollment periods although many changes occur then Families often not good at communicating changes Facilities don t routinely verify coverage 25 Enrollment Medicaid Managed Care New Eligible/Not in a Medicaid MCO Coming from home to NH (long term): Apply for Medicaid following all current regulations, including physician recommendation, PASRR process, Patient Review Instrument (PRI), etc. LDSS has 45 days to complete determination for long term Medicaid eligibility Once approved and any penalty period has elapsed and NAMI amount is identified resident has 60 days to choose an MCO NY Medicaid Choice will assist in education, plan selection and enrollment (in a plan with which the nursing home contracts) Auto enrolled if not select MLTC: No lock-in so enrollment may change 26 13

14 Enrollment Medicaid Managed Care Already Medicaid MCO Enrolled MCO must authorize all long term placements and pay the NH while long term eligibility is being conducted by LDDS NH and MCO assist with submitting documentation to LDDS (send MCO authorization with 3559) Member has 90 days from date long term placement is determined to submit the application for coverage of long term custodial placement to the LDSS LDSS will notify MCO, enrollee and NH o If eligible MCO keeps paying NH and NAMI is collected o If ineligible MCO recoup payment from NH and coordinate safe discharge into the community 27 Enrollment Medicaid Managed Care If a permanent nursing home FFS resident is hospitalized and ineligible for nursing home bed hold, upon return the resident will be viewed as a new permanent placement and will be required to enroll in a managed care plan Medicaid re-certifications the resident or designated representative is still responsible for submitting a Medicaid recertification. Nursing homes and MCOs are encouraged to assist. o If an enrollee does not appear on the plan s 1 st or 2 nd roster the plan is not obligated to pay the nursing home 28 14

15 Enrollment Considerations How do you track open enrollment changes? How will you track initial Medicaid managed care enrollments? How will you track enrollment changes? The provider must check eligibility and enrollment status at the time of service or weekly for NH services for billing purposes FAQ March 2015 Develop policies and procedures and provide staff training Failure to track may result in untimely billing to the correct payor 834 electronic enrollment files or will payor provide a roster? Enhanced communication with families? 29 Admission Authorizations Medicare Advantage and Commercial Authorization is generally required o Revenue Code or Level of Care Medicaid Managed Care If enrolled in a plan, MCO must authorize all long term care placements and will pay the nursing home while long term eligibility is being conducted by LDSS Authorization is generally required Responsibility for initiating authorization payor specific and timing is Ultimately SNF bears the risk if authorization is required but not obtained 30 15

16 Admission Authorizations Considerations All Managed Care Always verify if an authorization is needed and for what services admissions, routine services, supplies, equipment, etc. Payors may require authorizations for some plans but not others o Specific plan determines authorization requirements Document contact person and telephone numbers for future authorization extensions and reassessments 31 Admission Authorizations Considerations All Managed Care When is re-authorization required? What form? Portal or paper? o Electronic ~ $13.00 cost saving potential Can current staff handle the increase in work due to Medicaid Managed Care? o Case management vs floor staff vs billing staff vs new position? Coordination between billing and prior authorization staff o When/how/does billing get the authorization number? 32 16

17 Insurance Verification Medicare, Medicare Advantage Plan, Medicare Part D, Supplemental Plans, Medigap, Commercial Plans, Medicaid, Medicaid Managed Care, Medicaid Long Term Care Dual Eligible with original Medicare, Medicare Part D, Medigap and MLTC will have 5 insurance cards 33 epaces Eligibility Example 34 17

18 Insurance Verification Medicaid Managed Care Provider must check eligibility at the time of service and before billing o Currently may not be checking eligibility before billing Medicaid o Is this going to be a new process? o Will you do it for all payors? o Who is going to do it? o What resources will they use? 35 Insurance Verification Medicare FISS/Connex Check for each resident not just Medicare Part A admissions Payor websites or phone calls to each insurance Clearinghouse insurance verification portal Batch eligibility verification (271 / 271 files) Prior to billing submit 270 file for eligibility verification via clearinghouse Possible: submit excel spreadsheet to clearinghouse if billing system can t create a 270 file epaces / Plan Rosters Look at eligibility and Restriction/Exemption codes (institutional Medicaid, spend down) 36 18

19 Insurance Verification Best Practice Suggestions Staff training Identify type of coverage (MA, MLTC, Dual Advantage, MAP, etc.) AND name of plan (to be able to easily reference payor manuals) Document every call/contact in your billing system Complete verification before admission and billing 37 Billing and Post-Billing 19

20 Revenue Code/Level of Care Medicare Advantage and Commercial Billing formats may vary Revenue Code Excellus Medicare Advantage and Commercial UHC EverCare MVP 191 Skilled Nursing Level I Level A Continuing Care 199 Level Ia 192 Sub-acute Therapy Level II Level B Low Rehab 193 Sub-acute Rehabilitation Level III Intensive Service Delivery Level C High Rehab 194 Level D Medically Complex 39 Revenue Code Medicaid Managed Care Description Fidelis Care at Home Revenue Code Healthfirst Revenue Code Bed Hold Temporary Hospitalization Bed Hold Therapeutic LOA Bed Hold Other Therapeutic LOA 0189 N/A Room and Board + Ancillary Services 0190, 0191, 0192, (all inclusive custodial & respite) Room and Board Only 0190, 0191, 0192, (all inclusive custodial & respite) 40 20

21 Rate What rate is used? Medicare or Medicaid Rate Negotiated Per Diem UCC (Usual and Customary Charge) Pays lesser of daily rate or billed UCC rate 41 Billing Format Every new format creates added work Set up like another payor or plan? Which revenue codes? What rate? Which modifiers? Itemized or just room & board? Excluded services? 42 21

22 Billing Format Medicaid Managed Care Claim format may be similar to Medicaid format because rate code is required Claim format may be similar to HMO because authorization number is required Look at each plan and determine if a new claim format needs to be built Requires testing Maintain examples of clean claims for various bill types and service types for each payor and plan in your billing office 43 Billing System Consider the structure/design of your billing system Example: If only have Fidelis as a financial class it may be insufficient because there may be multiple Fidelis plans (not just MLTC plans) in your area and each plan is likely to have different billing and claiming requirements How does system handle rate variations within the same plan for level of care billing (higher rates for additional therapy utilization or nursing care)? Are rates loaded so contractual adjustments are calculated at billing which results in $0 balance when payment is posted? o Are contractual allowances correct for each plan/payor? If incorrect relies on staff to know if paid correctly and requires additional time at payment posting to enter contractual adjustments 44 22

23 Billing System Can billing system easily produce a clean claim? How many human interventions are needed? Electronic or paper or Direct Data Entry (DDE)? All Medicaid MCOs must be able to accept electronic claims Medicaid Managed Care Need to submit multiple batches of claims to multiple payors no longer just 1 weekly batch to Medicaid More time needed for submission and acceptance monitoring Can system produce payor and plan specific billing reports? How can system contribute to a denial management program? Set-up, tables, dictionary modifications needed? 45 Timely Filing Know timely filing requirements for each payor Most payors have a 90 day timely filing requirement Bill at least monthly no later than the 15 th Bill as often as payor will allow Maximize billing and payment cycle For Example: Medicaid Cycle 2082 o Start date = Thursday, 7/6/17 o End date = Wednesday, 7/12/17 o Check date = Monday, 7/17/17 o Check release date = Wednesday, 8/2/17 (3 weeks after end date) 46 23

24 Follow up / Collections Keep all claims alive with follow up Document every submission, mailing, phone call, etc. No more than days between follow up attempts Verify receipt of claim acceptance reports, fax confirmation, registered mail Utilize billing system collections module o If none write follow up on calendar Prioritize follow up by large dollar and timely filing Group calls by payor nearing 47 Denials Per AMA 1.38% 5.07% of claims are denied on 1 st submission Aetna 6.00% UHC 4.30% Cigna 3.80% Medicare 2.30% Need to work electronic rejection/acceptance reports Must review 999 and 277CA o 999 confirms that a file was received. However, the 999 includes additional information about whether the received transaction had errors. Accepted (A), Rejected (R), Accepted with errors (E) o 277CA acknowledges all accepted or rejected claims in the file Must work payor denials review remittances 48 24

25 Denials Industry shift toward managed care requires SNF to focus on denial management Denial management is old news to physicians and hospitals Long ago addressed in their billing systems and processes SNF billing systems and SNF process deficiencies: Many billing systems don t capture payment codes Many billing systems can t generate denial management reports Minimal use of clearinghouses and available denial-related reports Many SNFs don t post zero payments Most SNFs do not have a robust denial management program Consider additional report writing add-on software or programming 49 Denials Cost to re-work a claim Staff time $10.67 Supplies $ 1.50 Interest $ 1.75 Overhead $ 1.00 TOTAL $14.92 Key Performance Indicators (KPIs): % of denied claims <5% % of EDI denied claims <1% % of paid after 1 st appeal >75% Lag time to work denial < 5 days 50 25

26 Appeals Know each payors appeal process for each type of appeal Time limits (60 days, 90 days, per contract) Payment discount for timely filing appeal Specific forms Review your process for each type of appeal Who gathers the necessary documents? Who submits? Who monitors status? Are outcomes shared with all? o Are you learning from denied appeals? 51 NAMI Collection Estimate at admission and attempt to collect Medicaid Managed Care Initial implementation shifts responsibility to MCO and MCO may delegate it to NH or other entity o Should be outlined/agreed to during contracting o Make sure you have an internal process in place if agreement is different than your current norm o Long term plan State or designee will assume financial and operational responsibility to distribute NAMI and collect NAMI income 52 26

27 NAMI Collection Two important questions Who manages Social Security and other income? Does NH manage a resident fund of PNA money? If NH is rep pay it will never be free from NAMI responsibility Develop a spreadsheet to track $1,000 income Resident = $1,000 Plan collects from resident = $950 Resident give NH $50 PNA (or keep) Plan pay NH $950 $1,000 income NH rep payee = $600 Plan collects from resident = $400 NH keep $50 PNA NH keep $550 of NAMI Plan pay NH $ Polling Question Do you feel like you have the proper structure in place to effectively bill and get paid in a managed care environment? A) My current system seems to be working just fine B) We have had to make some changes and have been successful getting paid timely C) We are struggling and need to make some changes 54 27

28 Billing Department Re-Design Current silo structure may become ineffective Medicaid Managed Care o May be too much work for one person to handle o Medicare Advantage/Commercial blurring into Medicaid Managed Care Consider alpha-split or unit/floor split or shift additional FTE to Medicaid managed care billing 55 Clearinghouse Vendor that serves as a middleman between facility and payors Claims submission: Rather than sending paper claims or electronic claims to each payor as a separate transmission the clearinghouse is a centralized portal that receives your claims and forwards claims to the appropriate payors $2.04 per transaction savings opportunity Provides other valuable billing-related services: electronic remittance, eligibility verification, claim status, resident statement printing/mailing, payment portal If use ABILITY for Medicare now (IVANS NOW or EASE) consider CHOICE All-payor Claims and COMPLETE (eligibility) Others may be less expensive with equal or better service don t settle just because ABILITY is what your biller is used to Remember that free isn t always the best answer for operational efficiency 56 28

29 Expect More From Our Systems Common SNF Billing System / EHR Deficiencies Insurance verification (batch 270/271 files) Payment code posting Need reader for remittances Inadequate reporting and need for additional report writing software o Crystal reports, analytics programs, SQL database programmer Difficulty generating clean claims Difficulty in programming contractual adjustments Account notes and tickler system Lack of sophistication to handle VB arrangements o Bundled payments o Hospital readmissions by diagnosis reports o Length of stay by diagnosis reports 57 Other Opportunities 29

30 Internal Communication Inter-departmental must understand key components of plan and how they impact reimbursement and resident care/ coordination Contract, provider manuals, billing manuals available to all key players Develop summary page of each plan Need to keep updated 59 External Communications Families Enrollment status updates NAMI collection Hospital discharge planners Payors Make sure you are assigned a provider representative Develop a partnership with each payor representative Hold regular meetings They would much rather help up front than deal with you when you are frustrated 60 30

31 Clinical Implications Medicaid Managed Care Authorizations/notifications for transfers and other care services (routine, elective, urgent) Clinical staff will have to coordinate with payor case manager for many more residents Significant increase in time Coordination with vendors/suppliers More time required to coordinate coverage benefits Clinical Appeals More time spent by clinical, HIM, others Documentation changes needed? and 61 Case Manager Often a Nurse or Social Worker Certification through the Commission for Case Manager Certification (CCMC) or the American Nurses Credentialing Center (ANCC) Function as intermediary between SNF, residents and the payor balancing the fine line between the discharge goals of the payor, the needs of the resident and working with facility staff to recognize how care delivery changes may be needed to satisfy the discharge requirements of particular payor Monitor expiration, medical record submission dates and approvals of initial, ongoing and ancillary service authorizations Communicate care plan/service changes with payor 62 31

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33 St. Ann s Community Managed Care-How Have We Fared? Adelaida Samuels, CMC, CMBSI, Director of Billing Sabrina McLeod, Director of Finance 65 Agenda Maximizing the EMR system Transforming the billing department Managing the MLTC s Financial difference for Organization Cost Accounting 66 33

34 Maximizing the EMR system Check to see if the reimbursement rules are set up for each payer Can your system post payments electronically (ERA) without staff having to touch each account? EFT set up for all plans 95% of our claims are submitted electronically to payers. Make sure to review the 999 and 277CA Can your system produce specific billing reports by plan Do you utilize a clearing house? Utilize a clearing house that will allow you to run reports for denials by plan, days in AR, batch eligibility and claim analysis. 67 Managing the EMR system cont.. Can your system post payments electronically (ERA) without staff having to touch each account? A)Yes B)No C)N/A Can your system produce specific billing reports by plan? A)Yes B)No C)N/A Do you utilize a clearing house? A)Yes B)No C)N/A 68 34

35 Transforming the Billing Department Review duties each staff was assigned to do, surprisingly enough 50% of what they did was AR! That is not enough, as a biller the main job is AR. 80% of their time was devoted to collections and other duties were assigned appropriately. Follow up every 30 days EDUCATE, EDUCATE, EDUCATE!! Each Resident account rep is a Certified Medical Biller Specialist (12 CEU s needed a year) Ongoing staff training Each contact/call is documented in the billing system Each rep is responsible for a payer(s) 69 Billing Department Changes Are your billers certified as medical billers? A)Yes B)No All Resident account reps are Certified Medical Billers Cross training staff Loading the reimbursement rules in EMR system to create a clean claim Understanding the timely filing by payer AR follow up within 30 days Utilizing Clearinghouse for electronic submission and EFT DOCUMENT, DOCUMENT & DOCUMENT 70 35

36 Increased Administrative work for SNF s If the resident is enrolled in a MLTC plan, the plan must authorize all LTC placements. MLTC s are authorizing every 6 months and every 6 months reimbursement has to call and renew the authorization. If no authorization is obtain no payment $$$ Coordination between billing, admissions and reimbursement is key! 71 Managing MLTC s Have you hired someone to handle your MLTCs? A) Yes B)No Due to authorization and care coordination between the SNF s and MLTC we needed to hire a MLTC Reimbursement Case Manager and Financial Liaison. MLTC case manager is responsible for: Obtain initial authorization and ongoing authorization Provide MLTC with Monthly clinical follow up for their members, including notifying them of LOA, Hospitalization and major clinical changes. Coordinate the scheduling of MLTC on-site initial and quarterly assessment with MLTC Nurse and family member. Assist Resident and Family members with the selection of MLTC and providing them with information to make that selection. Central Point of contact for Resident, Family and Staff with any concerns with MLTC coverage

37 Managing MLTC s continue.. Medicaid Managed Care Rate-is the current FFS (benchmark) rate or negotiated rate ent/nhr/ If you negotiate you will need to renegotiate if it falls below current benchmark rate Submitting claims weekly to MLTC s Clean claim should pay within 4 weeks Know who your provider rep is for each plan, set up quarterly meetings 73 Financial Liaison Works in the same office as admissions Verifies insurance and review insurance coverage upon admissions Keeps track of private pay residents and counsels them on Medicaid when balances reach $25,000 Handles the LTC Medicaid application, outsource to agency if needed Works with resident and or family for Medicaid recertification Explains the MLTC and refer to MLTC reimbursement case manager 74 37

38 What did this mean for St. Ann s? St. Ann s Community has seen an increase in the number of Medicaid residents. As residents enroll into Medicaid it is mandatory they pick an MLTC plan. The process and timing of payments from plans to providers will be different than dealing with NYS Medicaid. This will cause an increase in AR due to payments coming in sporadically. Educate Medicaid billers on all the different MLTC plans and requirements. Provide a cheat sheet with revenue codes, type of bill and payer timelines. 75 How has this made a financial difference? The Billing Department redesign has financially benefited the organization by: 1. Marked decrease in AR not only in dollars but in days in AR 2. Increased cash flow for the organization 76 38

39 Decrease in AR Dollars Decrease of $3.5M 000 s omitted 77 Accounts Receivable - At the start % was current under 60 days outstanding 180+ Days 13% 120+ Days 12% 60+ Days 19% Current 56% 78 39

40 Accounts Receivable - Currently (2017) 76% of outstanding receivables are under 60 days outstanding 120+ Days 5% 180+ Days 8% 60+ Days 11% Current 76% 79 What does the future hold? Are you ready for rate negotiations with MLTC plans, including knowing how much it costs to care for individual residents? A)Yes B) No Get ready for rate negotiations with the MLTC plans That means knowing our costs down to the patient level How do we do that? Cost accounting system 80 40

41 What does the future hold? Cost Accounting Do you have a cost accounting system? A) Yes B) No A system that allows us to filter all of our financial information and compares that with our patient/resident census, diagnosis, pharmacy and other ancillary costs so that we can analyze costs down to the patient and/or diagnosis level For example we can evaluate the difference in costs for a sub acute patient that comes in after joint replacement with no comorbidities, and one that may have co-morbidities This gives us the information we will need to negotiate rates whether that is part of a bundled payment or just negotiating for a daily rate with an insurance company Gets us out of the per diem thinking 81 41