Imagine running a business where one of your customers never pays on time. Six months, eight months can go by before this customer finally cuts a check.
Now imagine that this one customer accounts for 25 percent of your total revenue, and can't be forced to pay any earlier. Because the customer is the government.
Welcome to Janet Burns' world.
Burns is the executive director of Sunny Vista Living Center, a nonprofit nursing home on East Cache la Poudre Street. (Disclosure: Independent executive editor Ralph Routon serves on Sunny Vista's board of directors.) As she explains it, the majority of Sunny Vista's funds come from Medicare or Medicaid. Medicare covers short-term care, such as post-accident rehab; Medicaid pays for long-term. Most homes, she says, collect almost 50 percent of their funds through Medicaid.
If a person has been approved for Medicaid before move-in, the finances are pretty straightforward. But often, a person moves in before being Medicaid-approved, especially if an unexpected fall or illness quickly forces a family to change a living situation.
Nursing homes typically take on these "Medicaid-pending" patients, and a monthly expense of $5,000 or more, with the understanding that the resident's family and the county's Department of Human Services will complete all necessary paperwork and trigger funding (including back pay) within 45 days, as per state guidelines.
Problem is, 45 days is often a pipe dream in El Paso County.
Paper trails and trials
Federal Medicaid dollars are administered through county DHS. The 26-page form it gives to applicants requests info on every aspect of your financial life, with appropriate backing materials. If it's lacking material, the applicant or their family is alerted and given 11 days to complete it; otherwise the application is denied. Approval or denial should come within those 45 days.
It took nine months for Margie Maddox's application to get processed. Her niece, Nona Hentschel, was the one who filled out and submitted the materials.
"I am an intelligent person. I have several degrees under my belt," says Hentschel, who is a retired teacher. But the process was "enough to make you want to scream."
Hentschel had been taking care of her aunt for 15 years, and only last summer applied for Medicaid. Her application was denied on July 12, 2010, for lack of proper paperwork.
Jennifer Goldwater, business manager for Sunny Vista, long ago began scanning copies of all documents submitted to DHS. She also started following up by e-mail, rather than phone, to create a clear timeline of what was sent and said when.
In Maddox's case, the e-mail conversation between Goldwater and DHS appears to show a frustrated Goldwater trying to get traction on an application that was completely submitted in May, but met with "incomplete paperwork" claims in July and August.
September, October and November elapsed, with e-mails unanswered, until Maddox was finally approved in December. She died in April.
Amazingly, there is still a three-month period of Medicaid payments that Sunny Vista has been unable to collect. The holdup? Just last week, Hentschel received a letter requesting Maddox's correct birthdate.
"Generally when we receive the application, it is not fully complete, in that it doesn't have all the required verifications attached to it," says Chris Garvin, program manager for DHS' Aging and Adult Services. "Long-term care can be very complicated. It is a case-by-case situation. Not everybody has the same resources or the same issues."
People have insurance policies, annuities, savings, vehicles, property and so on. There is an income limit for anyone applying for long-term Medicaid; an applicant can only have $2,000 in assets in his/her name. So for many, there is a long "spend down period" in which they simply spend or give away their modest assets. If a spouse will remain in the community, the equation's complicated by ensuring that applicant can qualify without bankrupting the spouse.
'Not playing bridge'
Garvin has a team of 14 processing long-term Medicaid applications, and says long-term care historically has had issues with compliance.
"We could probably use a few more staff," he adds, "but that is tied into budget issues with the county and the state."
Richard Bengtsson, director of county DHS, says Aging and Adult Services, like much of his department, has seen its workload increase significantly over the past four years — he guesses by 35 percent — while funding has lagged.
Goldwater would like to see Bengtsson and Garvin get more staff, too. "They are not playing bridge. They are working hard," she says. "But we are waiting for months."
According to a year's worth of weekly reports provided by Garvin, between 19 and 20 percent of long-term Medicaid applications coming through his department exceed the time guideline. As of May 12, according to information gathered by the Indy, Sunny Vista and two other county homes could count 29 claims breaking the 45-day limit. For each of these homes, such cases accounted for at least a quarter of their entire Medicaid caseload.
A number of these cases were more than 200 days old. One was 335 days old.
Burns carries a nearly constant outstanding balance of pending Medicaid payment around $250,000—roughly her whole payroll for a pay period.
Sunny Vista will, at times, stop taking Medicaid-pending residents, she says, like most homes in the county. "If we have 15 or 16, I'll stop. When they get approved, I'll take in a few more."
But, she asks, "How long can we continue to do this?
"If everyone stops taking Medicaid-pending at the same time, what's going to happen to those people?"