10-27-22 - Kelly Gusmano, Esq. appears on Rochester First News Addressing Medicaid reimbursement complications amid hospital capacity concerns.

Posted on October 27, 2022

ROCHESTER, N.Y. (WROC) — This week, county health leaders and local hospital officials are addressing concerns surrounding bed capacity ahead of the winter months.

They claim the main reason behind this is due to a lack of nursing home bed availability in the region. Another reason is Medicaid reimbursement rates not truly covering the real cost of care.

“We do not fault our nursing homes for being unable to take these patients. The nursing homes are also dealing with staffing shortages and Medicaid reimbursements rates that do not adequately cover the cost of the care they need to provide to these patients,” said Dr. Kathleen Parrinello, Executive Vice President and Chief Operating Officer of Strong Memorial Hospital, in a Tuesday press briefing.

“So we have several clients who have had very long stays in the hospitals lately. not because they need the care, but because they can’t go home, they can’t be cared for at home. And what happens is if you’re in the hospital and you’re no longer receiving skilled care, you have no medical need to be there, the hospital can’t bill your insurance,” said Kelly Gusmano, an associate attorney who specializes in Elder Care Law and Medicaid.

Gusmano explains, Medicaid budgets are based on a patient’s status; for example, whether they are admitted to a hospital, going home, or being sent to a nursing home.

“So we’re having clients where they’re having these prolonged stays, we get them on Medicaid but they still have to pay a lot towards their hospital bill so it’s causing backlogs, its causing confusion, it’s causing billing issues,” she said.

By law, a patient cannot be discharged from the hospital until a nursing home placement is complete. Dr. Parrinello noted Tuesday, Strong Memorial Hospital currently has an average of 100 patients awaiting placement, compared to two years ago when there were about 25 patients (also noted as a more standard number).

Private pay rates for nursing homes in our region, Gusmano says, typically range between $14,000 on the low end to upwards of $18,000.

A patient on Medicaid will be responsible for paying a small portion of the cost based on their income and Medicaid then comes in to cover the difference — but only *up to a certain amount, set by those reimbursement rates.

That standard is negotiated by the state and often revised, but often leaves a large amount of the real cost of care unaccounted for.

Those rates, she goes on to say, are typically negotiated with the state and often revised.
For example, a patient pays $1,000/month, Medicaid will cover up to a certain amount — set by that reimbursement rate.

“Unfortunately, it is substantially less than what they get privately and I think a lot of nursing homes are feeling the strain that it’s putting on their system because they’re not getting enough pay, they feel, to adequately provide for care, for staffing,” Gusmano says.

To address the nursing home bed shortage, hospital leaders say they are working with the State Department of the Aging to create a task force made up of local individuals. We’ve reached out to that office for more details.

The multimillion grant hospital leaders mentioned Tuesday, which will go towards helping train more nurses and provide financial support for nursing homes, will come from American Rescue Plan funds. County officials tell News 8 that funding still needs to be approved by the legislature next month.

Click on the link to watch the full interview on Rochester First WROC TV 8 News.


Kelly R. Gusmano