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Benchmarking: Drive Change Through
Financial and Operational Metrics
Presented By:
Tiffany Karlin, Partner and Director of Healthcare
Jeanette Bax-Kurtz, Partner and Director of Not-for-Profit
& Regulatory Services
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Full-service CPA firm with a specialty in Senior Living (IL, AL, SNF, HH&H & CCRCs)
Identified benchmarking as an area of interest and need through our work as consultants and fractional CFOs
Our goal is to provide practical solutions and insight that can be applied in your organization
Preferred Providers of Value1st
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Introduction
Why Benchmark?
CREDIT- CONTEXT – COMMUNICATION
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Access CreditCreate
Context
Communicate to Stakeholders
The Mindset2
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The Mindset2
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• Healthcare silos
• Flat or declining revenue
• Population being served within
brick and motor healthcare
services
• Inconsistent, unpredictable
cash flow
• Unmanaged receivables and
payables
• Weak or unproven internal
controls
• Extensive training time
• High employee turnover
• High dependence on a few
individuals
• Limitations on the availability
of meaningful, timely financial
information
• Keeping the status quo and
staying stagnant
• New pressures in a changing
healthcare system
• Planned revenue growth
• Population being served
wanting to stay at home and
maintain an active lifestyle
• Predictable and improved cash
flow
• Managed working capital
• Strong internal controls
• Consistent service quality
• Streamlined and documented
processes and procedures
• Happy, diversified, and skilled
workforce
• Meaningful, timely information
to manage the organization
• Increased organizational value
• Using research, benchmarking,
and vision to guide the
organization.
TOFROM
Common Questions In what areas could my organization improve and become more efficient? Is my organization prepared to manage a skilling nursing population under
Medicaid Managed Care? How is my organization controlling an aging population? How vulnerable is my organization to fraud and employee theft? How does my organization compare to others within my industry? Is my organization meeting the needs of the future of healthcare and
senior services delivery? How can I delegate more responsibility to my team without giving up control
of key decisions? What areas should I focus on to receive the largest return on my investment of time,
energy and money? Am I missing out on any “best practices” within my industry? Am I appropriately balancing the day-to-day operations with strategic planning for
the future?
Are my employees appropriately trained?
Is my organization staying relevant in the changing market?
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How Do I Unlock Opportunities?
Benchmarking
Comparing expected performance to actual (& understanding gaps)
Reviewing key processes
Assessing business and operational risks (impact vs. likelihood)
Collaborating with management team members
Planning strategically and tactically
Fostering relationships with key advisors (CPA, attorney, banker, insurance, financial planner)
Exploring partnerships
Strategic planning
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Benchmarking
What is Benchmarking?
The process of identifying and capturing data and evaluating this
data against oneself or an outside party (internal or external).
Types of benchmarking
Performance (e.g. financial)
Process (e.g. best practices)
Strategic (e.g. comparison to competitors)
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Why is Benchmarking Important?
Identify opportunities to reduce and/or manage costs
Identify competitive advantage
Identify opportunities to increase quality of service
Gain insight into relative strengths and weaknesses compared to
other organizations
Combat organizational complacency and the perception that
current performance is acceptable
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Why is Benchmarking Important?
(Continued)
Change the way it views its performance by providing both
qualitative and quantitative measures of effectiveness
Move beyond an assessment that is based solely on opinion
Avoid reimbursement penalties
Revenue and reimbursement optimization
Prepare for new payment models
Support the need for a transformation of processes or
even an entire organization
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Common Financial Ratios and
Performance Indicators
Financial ratios
Comparative analysis
Not-for-profit metrics
Healthcare specific metrics
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Financial Ratios
Current ratio
Quick ratio
Cash ratio
Days working capital
Accounts receivable days/Receivables turnover
Debt-to-net assets ratio/Debt service coverage
Interest coverage ratio
Revenue growth
Net operating margin
Efficiency Ratios
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Comparative Analysis
Current month to prior month
Current month to same month in prior year
YTD revenue and expense
Current YTD to prior YTD
Trailing twelve month (TTM) revenue and expense
Budget-to-actual
Variance reporting (monthly and budget-to-actual)
Common-sized financials
Footnotes explaining fluctuations in revenue and expense
Fixed vs. variable costs
Direct vs. indirect costs
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Not-for-Profit Metrics
Program efficiency
Operating reliance
Fundraising efficiency
Investment yield
Days cash reserve
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Healthcare Specific Metrics Census
Occupancy
Patient / resident days
Payer mix
Reimbursement rates / published rates
Medicare RUG optimization
Labor turnover
Overtime
Admissions, transfers and discharges
Hospital readmissions
Source of admissions
Length of stay
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Healthcare Specific Metrics (Continued)
Bed holds
Wages
Food costs
Supplies
Purchased services
Pharmacy
Five Star Quality Rating criteria
Nursing hours per patient day
Managed care contract rates
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Benchmarking
Data
Sources of Benchmarking Data
Internal
Historical financial data
Budgets and forecasts
Tax returns – Form 990
As filed Cost reports
External ProfitCents
D&B First Research
GuideStar
Charity Navigator
Ziegler, CAIN Bros (Financial
Institution of choice) Research
CMS cost reporting data
CMS Public Use File (PUF)
Certification And Survey Provider
Enhanced Reports (CASPER)
Medicare.gov
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Sources of Benchmarking Data (Continued)
Other External
Five Start Quality Rating
eHealth Solutions/PointRight
Data.Medicare.gov
Strategic Healthcare Programs (SHP) Data
CARF International
AHCA, LTC Trend Tracker
CMS Enterprise Portal
Provider Statistical Reimbursement Analysis Report (PS&R)
National Investment Center (NIC)
State Websites or Department of Health Contacts for State Cost Reporting Data
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Tools and Resources2
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Source: CARF Financial Rations & Trend Analysis Report (2017) National Investment Center Seniors Housing & Care Performance Report
ProfitCents
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ProfitCents
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Statement Of Activities
Last 12
Months 2016 2015
Last 5
Years
All
Years
Program Service Revenue 53.55% 53.55% 82.11% 76.40% 74.47%
Contributions 28.35% 28.35% 11.50% 10.66% 9.43%
Government Grants 0.00% 0.00% 0.50% 1.22% 5.17%
Investment Revenue 5.38% 5.38% 0.10% 5.59% 4.98%
Membership Dues 0.00% 0.00% 0.00% 1.62% 0.28%
Other Operating Revenue 11.73% 11.73% 2.93% 2.93% 4.45%
Net Assets Released From
Restrictions 0.99% 0.99% 2.85% 1.58% 1.22%
Total Unrestricted Revenue 100.00% 100.00% 100.00% 100.00% 100.00%
ProfitCents
Statement Of Activities
Last 12
Months 2016 2015
Last 5
Years
All
Years
Total Unrestricted Revenue 100.00% 100.00% 100.00% 100.00% 100.00%
Program Service Expenses 76.57% 76.57% 78.07% 76.21% 82.50%
Fundraising Expenses 0.38% 0.38% 1.08% 0.70% 0.85%
Administration Expenses 8.58% 8.58% 13.64% 12.02% 12.19%
Other Operating Expenses 1.76% 1.76% 9.86% 9.22% 5.48%
Total Operating Expenses 94.54% 94.54% 102.65% 98.15% 101.02%
Operating Yield (Net Operating
Gain/Loss) 5.46% 5.46% -2.65% 1.85% -1.02%
Other Inflows -0.41% -0.41% -0.85% 1.61% 1.83%
Other Outflows 0.00% 0.00% 1.67% 1.86% 1.30%
Total Change In Unrestricted Net Assets 5.11% 5.11% -5.17% 1.59% -0.49%
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D&B First Research
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D&B First Research
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Skilled Nursing Trends
Source: National Investment Center Seniors Housing & Care Performance Report
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MP “CMS Cost Reporting Data
Compare”Client Data
(PPD)
TX State
Compare Data
(PPD)
DifferenceNational Compare
Data (PPD)Difference
Cap-Rltd Costs-Bldgs. & Fixtures $38.20 $29.37 -$8.83 $26.80 -$11.40
Cap-Rltd Costs-Movable Equip $1.50 $2.28 $0.78 $3.37 $1.87
Employee Benefits $8.11 $20.82 $12.71 $29.86 $21.75
Administrative & General $11.55 $37.36 $25.81 $48.48 $36.93
Plant Operation, Maint & Rep $16.67 $13.17 -$3.50 $13.93 -$2.74
Laundry & Linen $0.60 $2.73 $2.13 $3.52 $2.92
Housekeeping $6.65 $5.97 -$0.68 $7.77 $1.12
Dietary $20.11 $16.47 -$3.64 $21.08 $0.97
Nurs Admin $1.06 $9.21 $8.15 $10.42 $9.36
Med Records & Library $0.00 $1.21 $1.21 $1.63 $1.63
Social Service $2.47 $2.51 $0.04 $4.15 $1.68
SNF - Participating $80.54 $61.44 -$19.10 $73.47 -$7.07
MP “CMS Cost Reporting Data
Compare” (Continued)
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Current Prior
CY Total PY Total Difference From PY to CY Occupancy % Occupancy %
Total Admissions 224 240 16 99.56% 77.14%
Total Discharges 171 254 83
CDP Licensed Beds 91 91 0
SCU Licensed Beds 0 0 0
OLTC Licensed Beds 698 98 (600)
Type CY Admissions PY Admissions CY Discharges PY Discharges
Medicare 130 111 121 114
Medicaid 0 0 0 0
Self-Pay 94 0 50 0
Managed Care 0 0 0 0
Other 0 129 0 140
Total 224 240 171 254
CY Medicare Average Length of Stay 24.74
PY Medicare Average Length of Stay 23.59
CY Total PY Total Difference From PY to CY
Medicare Census 2,993 2,689
Medicaid Census 0 0
Self-Pay Census 22,272 0
Managed Care Census 0 0
Other Census 0 22,934
Total Census 25,265 25,623 446.39%
Days in Receivables 57.98
Acid Test 0.07
Current Ratio 0.30
LTD to Assets 0.11
MP “CMS Rugs Compare Data”LE2 3500 29 450.40
LE1 3600 43 376.78
LD2 3700 22 432.87
LD1 3800 43 362.76
LC2 3900 17 380.29
LC1 4000 34 320.69
LB2 4100 14 361.01
LB1 4200 18 306.67
CE2 4300 13 401.32
CE1 4400 14 369.77
CD2 4500 11 380.29
CD1 4600 20 348.74
CC2 4700 11 332.96
CC1 4800 23 308.42
CB2 4900 10 308.42
CB1 5000 17 285.64
CA2 5100 14 261.10
CA1 5200 26 243.57
BB2 6300 14 276.87
BB1 6400 11 264.60
BA2 6500 12 229.55
BA1 6600 11 219.03
PE2 6700 17 369.77
PE1 6800 13 352.24
PD2 6900 18 348.74
PD1 7000 16 331.21
PC2 7100 18 299.66
PC1 7200 20 285.64
PB2 7300 13 254.09
PB1 7400 11 243.57
PA2 7500 15 210.27
PA1 7600 12 201.50
AAA 9900 32 201.50
Behavior
Symptoms &
Cognitive
Performance
Reduced
Physical
Function
Special Care Low
Clinically
Complex
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Worksheet S7
STATE National
Total Facilities 12,620
Total MCR Days 53,559,790
RUG-IV Group
CMS
LINE #
Facility
Days
Facility
rate
Avg.
days /
facility
Federal
rate
RUX 100 82 804.35
RUL 200 60 786.83
RVX 300 35 715.94
RVL 400 30 642.32
RHX 500 22 648.65
RHL 600 19 578.54
RMX 700 20 595.02
RML 800 15 545.94
RLX 900 32 522.56
RUC 1000 883 609.79
RUB 1100 1,200 609.79
RUA 1200 579 509.88
RVC 1300 361 523.13
RVB 1400 374 453.02
RVA 1500 256 451.27
RHC 1600 133 455.84
RHB 1700 109 410.27
RHA 1800 86 361.19
RMC 1900 75 400.46
RMB 2000 53 375.92
RMA 2100 41 309.31
RLB 2200 10 389.35
RLA 2300 5 250.88
ES3 2400 331 734.35
ES2 2500 36 574.85
ES1 2600 22 513.50
HE2 2700 32 495.97
HE1 2800 29 411.84
HD2 2900 26 464.42
HD1 3000 23 387.30
HC2 3100 22 438.13
HC1 3200 20 366.26
HB2 3300 18 432.87
HB1 3400 22 362.76
Rehab Plus
Extensive
Services
Rehab
Extensive
Services
Special Care
High
MP “Clinical Compare”2
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MP “Labor Turnover Compare”
EMPLOYEE TURNOVER REPORT
(2) (3) (4) (5) (6) (7) % %
BEGINNING # EMPLOYEES EMPLOYEES ENDING # HOW MANY FROM (5) ARE: EMPLOYEES TURN- RE-
SALARY CLASSIFICATION OF EMPLOYEES HIRED TERMINATED OF EMPLOYEES FULL-TIME PART-TIME RETAINED OVER TENTION
ADMINISTRATOR 1 0 0 1 1 1 0.00% 100.00%
CO-ADMINISTRATOR 0 0 0 0 0.00% NA
OTHER ADMINISTRATIVE 1 0 0 1 1 1 0.00% 100.00%
PLANT OPERATING 0 0 0 0 0.00% NA
DIETARY 0 0 0 0 0.00% NA
LAUNDRY 0 0 0 0 0.00% NA
HOUSEKEEPING 0 0 0 0 0.00% NA
DON 1 0 0 1 1 1 0.00% 100.00%
REGISTERED NURSES 3 1 1 3 3 2 33.33% 66.67%
LPN 8 1 2 7 2 5 6 26.67% 75.00%
LICENSED M/H TECH 0 0 0 0 0.00% NA
AIDES 23 10 11 22 18 4 14 48.89% 60.87%
PHYSICAL THERAPIST 0 0 0 0 0.00% NA
SPEECH THERAPIST 0 0 0 0 0.00% NA
OCCUPATIONAL THERAPIST 0 0 0 0 0.00% NA
RESPIRATORY THERAPIST 0 0 0 0 0.00% NA
PSYCH THERAPIST 0 0 0 0 0.00% NA
RECREATION THERAPIST 0 0 0 0 0.00% NA
RESIDENT ACTIVITY 2 0 1 1 1 1 66.67% 50.00%
SOCIAL WORKER 0 0 0 0 0.00% NA
MEDICAL RECORDS 1 0 0 1 1 1 0.00% 100.00%
OTHER HEALTH CARE 0 0 0 0 0.00% NA
TOTAL ALL CLASSIFICATION 40 12 15 37 28 9 27 38.96% 67.50%
40 12 15 37 28 9 27 38.96% 67.50%
(I) OK OK OK OK OK OK OK OK OK
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Labor Turnover:
• Lowered Productivity
• Overworked remaining staff
• Lost knowledge
• Training costs
• Interviewing costs
• Recruiters
Rug Potential2
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Source: Ability Network: RiskWatch
AHCA LTC Trend Tracker2
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AHCA Length of Stay Statistics for
2017Q1 - preliminary release
Median Length of Stay
CMS
Certification
Number Total Admissions Actual Median Expected Median
Risk-Adjusted
Median
015009 86 21 24.4 19.8
015010 328 18 23.5 17.6
015012 156 21 24.4 19.8
015014 27 39 32.1
015015 69 22 27.8 18.2
015016 302 21 25.3 19.1
015019 109 38 29 30.1
015023 69 21 30.5 15.8
015024 228 22 26.2 19.3
015027 192 21 27.5 17.6
015028 53 21 28.9 16.7
015031 463 21 26 18.6
015032 265 21 27.1 17.8
015034 70 21 30.1 16.1
015035 165 21 27.2 17.8
015037 20 27 26.5
015040 87 26 31.1 19.2
015042 83 21 27.2 17.7
015043 97 21 27.7 17.4
015044 11 63 39
015045 49 22 31 16.3
015047 26 26.5 34
AHCA LTC Trend Tracker2
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Medicare Compare
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Source: Medicare.gov/nursinghomecompare
Managed Care
Contracts
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Managed Care Contracting
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Managed Care
Contracts
Managed Care Contracting
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Managed Care Contracting
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Casper Report
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Quality Measures (QAPI)
Source: CASPER Reports & Ability Network: CareWatch
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Quality Measures (QAPI)
Source: CASPER Reports & Ability Network: CareWatch
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Hospital Readmissions: Track and Analyze
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Claims Errors
Source: Ability Network: UBWatch
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“MP” State Specific Medicaid Quality PaymentsQuality Assurance Supplemental Payments (QASP)
Quality Measures 2017-2018
Please complete cells in green only
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Grand Scoring
Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Total Point
Medi-Cal Bed Days
1 Fee for Service Medi-Cal bed days 25,876 Eligible
2 Managed Care Medi-Cal bed days 3,216
Total Eligible Bed Days -
MDS Clinical
3 Pressure Ulcers: Long Stay 0.97% 0.00% 0.49% 11.1110
4 Physical Restraints: Long Stay 0.00% 0.00% 0.00% 11.1110
5 Influenza Vaccination: Short Stay 97.93% 97.93% 97.93% 5.5558
6 Pneumococcal Vaccination: Short Stay 86.98% 86.98% 86.98% 5.5558
7 Urinary Tract Infection: Long Stay 1.30% 1.30% 1.30% 11.1110
8 Control of Bowel/Bladder: Long Stay 53.66% 53.66% 53.66% 11.1110
9 ADL Decline: Long Stay NA NA NA 11.1110
10 Self-Report Pain: Short Stay 13.04% 13.04% 13.04% 5.5558
11 Self-Report Pain: Long Stay 3.05% 3.05% 3.05% 5.5558
12 30-Day Rehospitalization: Short Stay 14.25% 15.79% 15.02% 11.1110
13 Staff Retention 78% 11.1110
14 Raw Points (Before MCBD and Staffing Standards) 100.0000
15 Facility Total Points 100.0000
16 Payout Tier Tier 3
Staffing
17 Nursing Hours per Patient Day (NHPPD) 3.96 Eligible
18 Number of Non-Compliant Days 0 Eligible
Citations
19 A/AA Citation Eligible Eligible
Incentive Payment
Eligible Eligible Eligible Eligible Eligible Eligible Eligible Eligible Eligible Eligible Eligible Eligible Eligible Eligible Eligible
Amount 33,567.00 35,892.00 69,459.00 416,754.00
Improvement Payment
Previous Year Eligibility (1 = Eligible) 1 1
Performance Year Eligibility (1 = Eligible) 1 1
Previous Year Raw Points 58.3300 58.3300
Improvement Score 41.67 41.67
Score in Top Percentile (1 = Yes) 1 1
Eligible Eligible Eligible Eligible Eligible Eligible Eligible Eligible Eligible Eligible Eligible Eligible Eligible Eligible Eligible
Amount 4,567.00 6,767.00 11,334.00 68,004.00
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Benchmarking Process Steps
1. Analyze financial and operational
benchmarking data
2. Identify potential opportunities
3. Consider financial impact of implementing
opportunities identified
Cash flow
Reimbursement
4. Consider non-financial impact of
implementing opportunities identified
5. Make “go” or “no-go” decision
6. Document decision
7. Implement
8. Monitor
9. Continuously improve
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Ways to Impact Revenue and Expenses
▪ Strive for timely, accurate financial information
▪ Share the appropriate data with the appropriate
people
▪ Utilize financial metrics and performance indicators
(e.g. revenue and cost drivers)
▪ Utilize clinical metrics and performance indicators
(e.g. revenue and cost drivers)
▪ Understand the root cause of variances identified
during comparative analysis
▪ Maximize billing and reimbursement rates
▪ Reduce billing errors
▪ Understand current and future referral sources
▪ Stay current on billing and collections
▪ Document and analyze root cause for rejected claims
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Ways to Impact Revenue and Expenses
(Continued)▪ Review / negotiate managed care contracts (rates, exclusions, etc.)
▪ Analyze contract profitability
▪ Utilize budgets and set goals
▪ Analyze fixed vs. variable costs
▪ Analyze direct, indirect costs and overhead
▪ Establish expense approval processes
▪ Centralize purchasing
▪ Pay attention to employee satisfaction and absentee trends
▪ Control overtime and excess capacity
▪ Review key processes for efficiency, waste and internal control
▪ Incorporate automation when appropriate
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Case Study
Fact pattern
Objective
What-ifs
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Questions?
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Thank You!
Tiffany Karlin
Partner and Director of Healthcare Services
tkarlin@muellerprost.com
314-480-1288
Jeanette Bax-Kurtz, CPA
Partner and Director of Not-for-Profit &
Regulatory Consulting
jkurtz@muellerprost.com
314-814-4943
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