What the North Carolina Medicaid managed care bill means for your practice

In a delayed step toward Medicaid expansion, North Carolina implemented a law in July that is impacting healthcare providers across the Tar Heel state. As one of the few states holding out on Medicaid expansion under the Affordable Care Act (ACA), the state passed legislation that calls for “privatization of Medicaid in North Carolina, switching to a model that involves the state contracting with for-profit managed care companies.”1

These Medicaid managed care plans are part of Gov. Roy Cooper’s efforts to expand Medicaid under the ACA. Healthcare providers are already feeling the impact of the new measure.

How the new law is impacting NC providers

First, with expansion of Medicaid, more patients will be eligible for Medicaid plans. As a result, you will likely see more patients moving between these plans to find the best fit for their healthcare coverage needs.

Under the new law, Medicaid beneficiaries may change their plans for any reason within the first 90 days of coverage.2 With plan changes, you will likely see an increase in the need for eligibility verifications for many of your patients.

Also, with the privatization of Medicaid plans, providers may lose the capability to submit claims through the North Caroline state Medicaid portal. Claims submissions will likely need to be completed through individual payers’ portals – or through a clearinghouse service – if the state site is no longer an option.

With this step toward Medicaid expansion in North Carolina, you can expect to see more patients covered by Medicaid managed care plans. This may impact your payer mix, creating new challenges for billing and claims management workflows.

Along with the challenges come new opportunities. Fortunately, with the right eligibility verification and claims submission technology, providers can meet current and emerging challenges head on. To find out how ABILITY can help automate eligibility checks and streamline claims submissions, request a demo today.


  1. “North Carolina and the ACA’s Medicaid Expansion,” Louise Norris, healthinsurance.org September 14, 2020. https://www.healthinsurance.org/medicaid/north-carolina/
  2. Open Enrollment Information for NC Medicaid Managed Care”, Brunswick County Government website. Accessed Sep. 23, 2021, https://www.brunswickcountync.gov/2021ncmedicaidmanagedcare/

How to get your SNF survey-ready

In addition to enhanced oversight around infection control at skilled nursing facilities, CMS has authorized states to step up routine surveys. How prepared is your facility for a routine inspection or a special focused survey?

Key regulations to understand

Survey readiness begins with understanding clinical quality programs and reporting requirements that directly impact survey results, such as:

  • Quality Assurance and Performance Improvement (QAPI) program
  • The Special Focus Facility (SFF) program
  • SNF Quality Reporting Program (QRP)
  • Federal tags and how they’re calculated

Survey results directly impact your business

SNFs should take steps to adequately prepare for surveys. A low survey score can result in:

  • Lower Medicare and Medicaid reimbursements
  • Financial penalties
  • Decreased star ratings
  • Fewer referrals
  • Reduced revenue

Data is critical to survey success

Without a doubt, survey preparedness and accurate quality data are paramount to SNF survival in today’s healthcare environment. The processes you develop, and your documentation are essential to shining on a survey.

Without a data-driven approach, survey success is an uphill battle. Fortunately, ABILITY CAREWATCH enables you to use your facility’s quality data to help surveys go smoothly.

Take the guesswork out of surveys with ABILITY’s easy-to-use application. Discover how in our on-demand webinar.


ABILITY and design®, ABILITY® and CAREWATCH® are trademarks of ABILITY Network, Inc.

Celebrate Heart Awareness on World Heart Day with ABILITY CAREWATCH®

As World Heart Day approaches, ABILITY Network would like to encourage everyone to be heart aware.

The heart is the strongest muscle in the body, but worldwide, more people die from cardiovascular disease every year than from any other cause.1 This makes attention to heart health imperative.

For long-term care providers, one way to prioritize resident heart health is by utilizing features within ABILITY CAREWATCH®, such as Diagnosis Watch. This feature tracks heart-related diagnosis codes for all residents – but identifying residents with heart conditions is just the first step. The real benefit is using this information as a guide in establishing staff training programs around looking for heart-related condition signs and symptoms and how to care plan properly. Not only can this education improve the lives of your residents, but it can also assist you with survey preparedness.

We believe proper training is essential, and to support you and your team, we have a staff of nurses ready to meet your educational needs as well as application support needs. Our team is continuously trained on the latest CMS rules and regulations and other areas of post-acute care.

One of our senior clinical educators is Sarah Becker, RN, RAC-CT, QCP.

Sarah recently hosted a customer webinar on determining the proper PDPM primary diagnosis. The presentation explored several of the PDPM rules, with scenarios to show how to choose the primary diagnosis on an MDS assessment using the ABILITY CAREWATCH ICD-10 Lookup tool.

For example, let’s evaluate the use of ICD-10 code I10 (hypertension) versus code I110 (hypertension with heart failure). Using I10 as a primary diagnosis code in an MDS assessment would yield no payment, whereas I110 would be acceptable for the PDPM Clinical Category, “Cardiovascular and Coagulations.”

ABILITY values the importance of maintaining education in all areas of life, including cardiovascular disease and overall heart health, and we encourage everyone to learn more at the World Heart Federation.


Featured Clinical Educator

Overcoming quarantine to serve patients in a mental health crisis with telehealth

Faced with a sudden shelter-in-place order in April 2020, mental health therapist Lys Hunt needed a way to serve her patients through the pandemic. Before COVID-19 hit, Hunt had only a single patient who didn’t attend in-person sessions at her office. With this shelter-in-place order, she suddenly needed a telehealth solution for 15 patients per week.

Turning to video conferencing and telehealth tools that she’d previously used on a limited basis, it was clear to Hunt that these platforms could not accommodate a full schedule of patient appointments. Connectivity and customer support issues became apparent very quickly, and Hunt knew she needed to make a change to serve her patients through this difficult time.

With an emerging mental health crisis due to COVID-19, Hunt needed an application that made it easy for her patients to meet with her virtually. Because the therapist was already using ABILITY for billing, ABILITY’s telehealth application felt like a natural choice. With virtual scheduling and billing capabilities in one place, and a user-friendly platform, the transition has been seamless. Hunt has maintained a full case load throughout the pandemic, helping patients who otherwise could not have received desperately-needed mental health care.

While Hunt has begun reintegrating in-person appointments, she and her patients have no plans to go back to 100% in-office sessions. For some patients, who moved farther from Hunt’s practice during the pandemic, telehealth gives them the freedom to continue working with a therapist they know and trust. And vulnerable patients have the capability to continue to care for their mental health without putting their physical health at risk.

For more details on how ABILITY helped this New England therapist respond to a burgeoning mental health crisis in the face of quarantines, check out our case study.

Want to learn more about improving access to care with a telehealth application that goes the distance? Schedule a demo today.

ABILITY and design® and ABILITY® are trademarks of ABILITY Network, Inc.

Ten steps SNFs must take for stronger infection protection and control

Skilled nursing facilities (SNFs) face unique challenges when it comes to infection prevention and control. The close-contact nature of SNFs and an older adult population – many with underlying medical conditions – put residents at increased risk of severe illness from infectious diseases.

Due to the elevated risk of contracting infections, SNFs need to be on alert to prevent infections and ensure the facility is as safe an environment as possible. According to the CDC, “a strong infection prevention and control (IPC) program is critical to both residents and healthcare personnel.”

While federal regulations have been in place since 2016 that require facilities to have infection control and prevention programs, the COVID-19 pandemic has brought renewed attention to the oversight of these programs. For example, the Centers for Medicare & Medicaid Services  (CMS) recently instituted a rule that requires SNFs to report COVID-19 vaccination status for residents and staff.

If ever there was a time to step up your organization’s infection prevention and control to limit potential transmission routes and reduce overall risk, it’s now. Every SNF is required to have a program that investigates, controls and keeps infection from spreading.

Here are ten steps you can take to combat infectious disease, comply with regulations, and improve patient outcomes at your organization:

  1. Educate all staff on hygiene guidelines and infection protocols
  2. Monitor adherence to facility-wide infection prevention procedures
  3. Stay up to date on regulatory and reporting requirements
  4. Employ a professional infection preventionist
  5. Hold regular infection control committee meetings
  6. Designate someone to coordinate IPC program activities
  7. Incorporate infection control into your QAPI process
  8. Perform infection surveillance with ongoing analysis of the data
  9. Implement a system to streamline regulatory reporting
  10. Understand the pertinent federal tags and prepare for infection-focused surveys

Ready to take your IPC program to the next level? ABILITY can help.

Watch our on-demand webinar to learn how you can streamline and proactively manage your infection control process for better outcomes.

ABILITY and design® and ABILITY® are trademarks of ABILITY Network, Inc.

Is the Value-Based Purchasing program on its way out? What SNFs need to know.

The SNF Value-Based Purchasing (VBP) program is in for an overhaul. The Medicare Payment Advisory Commission (MedPAC) has been advocating to replace the current program with an alternative that is more equitable across skilled nursing providers and that builds in financial incentives to motivate quality improvement efforts more effectively.

On July 29, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that includes raising the number of quality measures in the program. Here’s what SNF organizations need to know about the upcoming modifications to the SNF VBP program.

Why is the SNF VBP program changing?

The SNF VBP program is supposed to reward SNFs with incentive payments that reflect the quality of care provided to Medicare beneficiaries. However, in a mandated assessment, MedPAC concluded that there were “fundamental design flaws” in the current SNF VBP program and recommended it be “replaced as soon as possible.”

According to the Commission, shortcomings of the program include:

  • Use of only a single outcome measure – hospital readmissions – to assess performance
  • A reward system that does not motivate all providers to improve quality
  • Failures to address social risk factor variations across patient populations
  • Not distributing all withheld funds

What changes are expected?

The FY 2022 SNF Prospective Payment System (PPS) Final Rule lays out the following the provisions that will impact the SNF VBP:

  • The Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) will be suppressed for FY 2022 due to COVID-19
  • All participating SNFs will be assigned a performance score of zero to address possible distortion of performance scores and incentive payment multipliers
  • The federal per diem rate for each SNF will be reduced by 2%, and 60% of the withhold will be awarded back, resulting in a 1.2% payback to those facilities that meet their targets
  • Up to nine additional measures may be applied to the SNF VBP program beginning in FY 2024

What’s next and how can SNFs prepare?

The expanded SNF VBP will undoubtedly incorporate multiple performance measures, focus on patient outcomes and resource use for scoring and account for social risk factors.

While any new changes are limited to functional status, patient safety, care coordination or patient experience, new measures will still need to go through the rulemaking process. Currently, CMS is considering measures that are already required for long-term care facilities (LTCFs) in addition to input provided by stakeholders.

The best way for SNFs to prepare is to ensure their quality programs include technology to track quality metrics and provide analytics to improve performance.

This can be achieved with ABILITY CAREWATCH, a proven application that helps organizations simplify quality management, monitor their incentive multiplier, stay current with regulatory changes and optimize incentive payments under SNF VBP.


ABILITY and design®, ABILITY® and CAREWATCH® are trademarks of ABILITY Network, Inc.

Using telehealth to expand care and protect vulnerable patients

When the COVID-19 pandemic hit, therapist Janet Dyer had to quickly find a way to serve all her patients – without compromising their health or her own. As an immunocompromised person herself, Dyer needed to protect her own health so that she could continue to serve the 20 patients per week who depended on her for mental health care.

Despite being physically vulnerable, Dyer didn’t even consider closing her doors. Instead, she turned to telehealth services.

Dyer was not a complete stranger to remote mental health therapy. Prior to the pandemic, she had offered limited telehealth services to a few patients. She never considered expanding those services, though, as scheduling and connectivity obstacles made it too challenging to work at scale.

Faced with the need to provide a safe means to treat all of her patients, Dyer turned to ABILITY for a HIPAA-compliant telehealth application that offered easier scheduling, reliable connectivity and features like group appointments and screen sharing.

Her patients immediately embraced the convenience of the app, enjoying easy access directly on their phones or from their email. The app’s integration with their calendars and the automated appointment reminders made it easier for many patients to get the help they needed.

Discussing the improved efficiency and ease for her patients, Dyer said, “My patients don’t have to do a lot of planning and work for their appointments. They can wake up at 7:55 for an 8:00 appointment on a Saturday morning.” Unsurprisingly, many patients have indicated that they want to continue seeing Dyer via telehealth instead of returning to the office.

While patients enjoy increased convenience – and the freedom to conduct their therapy session in their car, home or even a local park – Dyer appreciates the efficiency of a single source for all her telehealth-related tasks. The application has saved her time and helped her streamline non-patient-focused tasks – so she can spend more time where it counts: with her patients.

For more details on how ABILITY helped Dyer serve her patients safely through a global pandemic, check out our case study.

Want to learn more about expanding care with a telehealth application that goes the distance for you and your patients? Schedule a demo today.

Easy claims management: how a billing consultant keeps it simple

When you think of healthcare claims, “effortless” is not usually the word that comes to mind. Quite the opposite, in fact. But that’s how one billing consultant described her experience using ABILITY’s claims management application.

Regina Burnham is a billing and account management consultant who works with behavioral health providers. To provide the best service to her clients, she needs to manage multiple claims with multiple payers – while maintaining efficiency and accuracy.

Burnham began using ABILITY CHOICE All-Payer Claims to automate her manual claims process. Now, several years later, she still counts on the application to simplify her billing. She explained, “I stayed with it because of the ease of submitting the claims.”

Even Medicare claims don’t slow her down. “ABILITY takes the pain out of getting Medicare claims set up so they can be submitted efficiently,” she said. “And they’re clean claims when they go out.”

Burnham submits her claims with confidence knowing she doesn’t have to choose between speed and accuracy.

View her story to learn more about her experience and how her claims management has transformed for the better.


ABILITY and design®, ABILITY® and ABILITY CHOICE® are trademarks of ABILITY Network, Inc.

5 ways to maximize revenue on every claim

Hospitals and health systems have long struggled with creating, growing and maintaining healthy revenue cycles.

The pandemic introduced new challenges when many facilities were forced to cancel elective procedures, dealing a hefty blow to balance sheets across the country. As your organization regains its footing, what are some of the most impactful strategies for recovery?

First, find your revenue

Let’s start with a number that’s hard to ignore: $660 billion. That’s how much hospitals have lost to uncompensated care since 2000.1

This means care was provided, revenue was earned, and it wasn’t collected. Ouch.

Adding insult to injury, nearly half of hospitals have experienced an increase in uncompensated care and bad debt resulting from the pandemic.1

Now, the good news.

There are simple steps you can take to drastically reduce the odds of self-pay accounts resulting in uncompensated care or underpayments. In many cases, you can side-step the risk of self-pay altogether.

Identify all available coverage

When you have a full view of all active insurance coverage, you can be reimbursed directly from payers instead of patients. It’s easier than you think.

ABILITY offers a superior insurance discovery tool that can help providers find up to 20% more billable coverage for unpaid accounts.2

Submit claims with renewed confidence knowing that you can avoid downstream denials and rejections by identifying all coverage information from the point of initial patient access.

ABILITY Insurance Discovery delivers the following key advantages to providers:

  1. Demographic information verification – Verify nine key elements in real time, note missing data and obtain complete, accurate info for each patient and claim.
  2. Active coverage identification – Numerous database searches identify unique primary, secondary and tertiary coverage, rank that coverage, and reveal managed care and advantage replacement plans.
  3. Expanded payer search – Run an average of 13 transactions per patient and find up to double the number of payers compared to other services.
  4. Geographic payer search – Conduct national searches and query the most relevant payers using proprietary matching algorithms.
  5. Customizable workflow capability – Create custom exclusions to eliminate false coverage and establish rules based on facility, patient, state and payer.

What kind of impact is this having on collection rates? Read the story of how an ABILITY customer in Florida experienced double-digit increases in insurance collections for hospitals and other providers.

It’s time to find out how much uncompensated care is costing you, and learn more about how ABILITY can help.



1 “Hospital Uncompensated Care Costs Grew to $41.61B in 2019,” Jacqueline LaPointe, RevCycle Intelligence, January 26, 2021, https://revcycleintelligence.com/news/hospital-uncompensated-care-costs-grew-to-41.61b-in-2019

2 ABILITY internal reporting, July 2021. Individual results may vary.

ABILITY and design® and ABILITY® are trademarks of ABILITY Network, Inc.

How an insurance discovery app drove double-digit increases for a collections agency

How do you improve your collection efforts when you’re faced with limited access to both data and insurance carriers?

Every collection agency has its challenges, but Marie St. James, Chief Operating Officer at Gulf Coast Collection Bureau, was dealing with limited data and delays that significantly impacted collection rates. So, not only did she need to find a way to make improvements, but she also needed to find a partner that could deliver on its promises.

“The biggest challenge with other vendors,” mentioned St. James, “was that they didn’t have the option for bigger carriers such as Blue Cross Blue Shield.”

With the account data the agency received already sitting at 90 to 120 days, timely filing was a constant and critical concern. Combine that with a vendor platform that was not user-friendly, and they found that their collection rate suffered. The organization needed a simple application with improved functionality that didn’t require constant communication with an IT team.

ABILITY Insurance Discovery provided the carrier access and straightforward functionality that strengthened collection efforts across the board.

By switching to ABILITY, the organization can focus more on the collection process instead of simply trying to access data in a readable format. Now, they have improved efficiencies, agents can more easily capture necessary information, and they have increased collections by 10%, according to a recent case study.

Ready to see how this innovative application can help you find more billable coverage? Schedule a demo today to see ABILITY Insurance Discovery in action.