MaineCare

Read this if you are a CEO, CFO, COO, Controller, Financial Analyst, or in a leadership position at a Critical Access Hospital. 

For many Critical Access Hospitals (CAHs), year-end Medicare settlements can be unpredictable—sometimes exceeding expectations, sometimes leaving an unexpected shortfall. These surprises often stem from a lack of proactive reimbursement modeling, and they can have real consequences for cash flow, operations, and long-term planning. The good news is that with the right tools and strategies, CAHs can anticipate settlements, make informed decisions, and strengthen their long-term sustainability. 

Why Medicare settlement surprises happen 

One of the most common pitfalls we see is failing to evaluate how operational decisions affect cost-based reimbursement. Not all costs are reimbursable, and even reimbursable costs do not influence Medicare reimbursement equally. For example, investing in a building renovation, such as modernizing patient rooms or repurposing space for nonclinical functions, may increase depreciation, interest, and allocated overhead costs. However, if the renovated space supports non-reimbursable activities or shifts square footage away from patient care cost centers, the investment may result in little to no increase in Medicare reimbursement despite its operational and community value. Without modeling these impacts in advance, well-intended decisions can unknowingly dilute cost-based reimbursement. 

Another frequent issue is not estimating Medicare settlements regularly throughout the year. Without timely estimates, hospitals lack visibility into expected reimbursement and are effectively operating without actionable insight until the year-end cost report is prepared. Once that point is reached, opportunities to adjust operations or proactively manage cash flow have largely passed. As a result, CAHs may overlook opportunities to request interim rate adjustments during the year, an important mechanism for improving cash flow and better aligning reimbursement with current cost structures. This is particularly impactful for Medicare Advantage plans, which typically reimburse based on interim rates and do not reconcile to actual costs, magnifying the financial consequences of outdated or inaccurate rates. 

Developing a proactive reimbursement strategy 

To reduce financial risk and strengthen financial management, CAHs should adopt a strategy that combines regular modeling of Medicare reimbursement, proactive planning, and team-wide education. 

We recommend implementing a Medicare reimbursement model that can be updated monthly, or at least quarterly. The model can help track trends, anticipate settlements, and inform operational decisions. Importantly, it should be flexible enough to account for changes throughout the year and provide insight into when a hospital should request an interim rate adjustment. 

Hospitals should model the reimbursement impact before making any major operational changes. Whether it’s launching a new service line, expanding square footage, or adjusting staffing levels, modeling can help clarify whether those changes will improve, reduce, or have little effect on Medicare reimbursement. 

In addition to operational planning, reimbursement modeling should be fully integrated into capital planning and long-term strategic investment decisions. Many CAHs pursue facility expansions, technology upgrades, or new clinical services without fully evaluating how those investments will affect Medicare cost-based reimbursement. By modeling reimbursement impacts and incorporating them into ROI analyses, leadership can make more informed, data-driven decisions, prioritizing projects that advance the hospital’s mission while also strengthening margin and supporting long-term financial sustainability. 

To fully realize the benefits of proactive reimbursement modeling, it’s essential that hospital leadership and finance staff understand the fundamentals of Medicare cost-based reimbursement, including how costs flow through the cost report and ultimately impact settlement. Knowledge at all levels ensures operational and strategic decisions are aligned with reimbursement realities. 

Options for estimating Medicare settlements 

There are two primary methods that CAHs can use to estimate their Medicare cost-based reimbursement throughout the year: preparing an interim cost report or using a reimbursement model. 

Preparing an interim cost report mirrors the actual Medicare cost report process and provides a detailed, accurate picture of expected reimbursement. This approach can be time-intensive for finance teams and, as such, these reports are often only prepared once toward the end of the fiscal year, limiting their usefulness for real-time decision-making. However, it is often the best choice when a hospital has experienced significant operational changes, particularly those affecting overhead allocations such as expanding into new space or launching a new service line.   

Using a reimbursement model offers more flexibility and can provide regular insights throughout the year. Hospitals can choose from different levels of complexity depending on their needs: 

• A step-down model closely replicates the cost report by using detailed statistics and overhead allocations. This type of model is best suited for quarterly updates as it can be relatively burdensome. If revisions to overhead allocation details are needed, some hospitals instead opt to complete an interim cost report. 
• A high-level relational model estimates reimbursement based on prior year cost report data, adjusted for high-level changes in revenue and expenses. This model is simple to use and ideal for monthly updates, though it may be less precise. If a hospital has experienced significant operational changes, this type of model may not be the right fit. 
• A departmental model strikes the right balance for many hospitals. It applies current revenue and expense data at the department level to capture service mix changes and departmental cost-to-charge ratios, while using consistent reclassifications, adjustments, and overhead allocation ratios from the previous cost report. This model can be updated monthly or quarterly and tends to offer greater accuracy without becoming overly burdensome.  

While a model provides critical visibility throughout the year, it’s important to recognize that if substantial operational changes occur, an interim cost report may still be necessary to reflect those changes accurately in your estimates. 

Turning insights into action 

Ultimately, the most successful CAHs treat Medicare settlement estimation as a year-round activity—not a once-a-year event. By proactively estimating cost-based reimbursement, you can avoid cash flow surprises, justify interim rate changes, and better align operational and strategic decisions with reimbursement outcomes. 

Whether you’re building a model for the first time or looking to refine your current process, BerryDunn can help you choose the right approach for your hospital, design and customize a model to your needs, train your finance and leadership teams, and support your financial planning throughout the year. Learn more about our team and services. 

Local governments are at a pivotal moment. As retirements accelerate and community needs shift, traditional hiring methods are no longer enough to build resilient, diverse teams. More than half of U.S. states, including the state of Washington, have adopted policies encouraging skills-based hiring, and in states with these policies, 22 out of 25 saw their share of job postings without degree requirements increase (National Governors Association, 2024). This shift is helping governments address talent shortages and diversify their workforce. To meet today’s challenges, local governments must embrace skill-based recruitment—an approach that values practical abilities and real-world experience. 

For further guidance, see the State of Washington’s Executive Order 24-04 Toolkit. While the Executive Order applies to state agencies, local governments may find these resources helpful in shaping their own skills-based hiring practices. 

Why traditional hiring methods are no longer enough 

In today’s public sector, workforce shortages are common, and the pace of change is relentless. New challenges in public health, infrastructure, and digital services demand skills that may not be reflected in a candidate’s formal education or years of experience. Too often, traditional hiring overlooks those who have gained expertise through nontraditional paths—military service, community leadership, or hands-on technical work. 

Local governments must ask themselves: Are we missing out on talent by focusing too much on credentials? By shifting the lens to skills and competencies, agencies can tap into a broader pool of candidates, foster innovation, and ensure continuity in essential services. 

The challenge of credential-focused hiring 

Credential-focused hiring can unintentionally create barriers. Job postings that require specific degrees or a set number of years in a particular field may exclude candidates with relevant experience gained elsewhere. This approach also tends to favor those with uninterrupted career paths, overlooking individuals who have taken employment gaps for caregiving, education, or other reasons. 

Consider the resident who has managed complex projects in a local nonprofit or led teams in a small business. They may be just as qualified as someone with a formal degree, but rigid requirements keep them out. Overreliance on credentials can also lead to homogeneous teams, limiting diversity of thought and experience—something local governments cannot afford as they strive to serve increasingly diverse communities. 

Best practice: Audit your job postings. Are there degree or experience requirements that could be replaced with practical skills? 

Building community talent pipelines 

The solution starts with community engagement. Local governments can build robust talent pipelines by partnering with colleges, trade schools, and organizations that serve nontraditional candidates. These partnerships help align curricula with the real needs of public service, ensuring graduates are ready for the challenges ahead. 

Welcoming candidates from alternative career paths—veterans, caregivers returning to work, or those switching industries—broadens the talent pool and strengthens the workforce. Outreach programs and mentorship are critical for raising awareness of local government careers and helping candidates develop the skills needed for success. 

Best practice: Reach out to local schools and organizations. Launch an outreach campaign to promote public sector opportunities and offer mentorship to new candidates. 

Shifting from degree requirements to demonstrated competencies

At the heart of skill-based recruitment is a focus on competencies. Local governments should define the core skills required for each role, moving away from unnecessary degree requirements. Hiring managers can be encouraged to value diverse experiences, recognizing that adaptability, problem-solving, and communication are often more important than formal credentials.

Updating job descriptions to emphasize essential and adaptive skills helps attract a wider range of applicants. Clearly distinguishing between “must-have” and “nice-to-have” requirements ensures postings are realistic and inclusive. 

Best practice: Rewrite one job posting this quarter to focus on skills and competencies instead of degrees. 

Rethinking resumes and screening processes 

Skill-based recruitment means looking beyond degrees and job titles. Reviewers should seek evidence of practical experience—project outcomes, leadership roles, technical achievements. Removing bias is crucial: anonymizing applications and training hiring managers to recognize unconscious bias helps ensure fairness. Using objective, skill-based criteria for initial screening levels the playing field for all candidates. 

Practical assessments, such as job-relevant tasks or simulations, allow agencies to evaluate problem-solving, communication, and technical skills directly. Fairness and transparency in assessment methods are essential, and candidates should be evaluated based on real-world achievements. 

Best practice: Pilot a resume review process that highlights skills and anonymizes candidate information. Add a practical skills assessment to your next hiring process. 

The payoff: a diverse and adaptable workforce 

Skill-based recruitment offers significant benefits. By focusing on what candidates can do, local governments build teams that are more diverse, adaptable, and resilient. This approach helps fill critical gaps, fosters innovation, and ensures that public services remain responsive to changing needs. 

Embracing innovative hiring practices is not just a matter of policy—it is a commitment to building a future-ready workforce. Local governments must lead by example, adopting inclusive and practical recruitment strategies that reflect the values and needs of their communities. 

A call to action for local government leaders 

Now is the time to review hiring practices, update job descriptions, and invest in outreach and training programs that prioritize skills over credentials. By taking these steps, local governments will open doors to a wider range of candidates, strengthen their teams, and deliver better outcomes for residents. 

Building a future-ready workforce requires courage, creativity, and collaboration. By embracing skill-based recruitment, local governments can empower progress and drive public sector excellence for years to come. 

Focused on inspiring organizations to transform and innovate, BerryDunn’s Local Government Practice Group can help you solve your biggest challenges for your organization as a whole and in specific areas. Our team is comprised of broadly specialized consultants and former local government employees that exclusively serve local government clients. Learn more about our services and team. 

Launching a Constituent Relationship Management (CRM) initiative isn’t just a software upgrade, it’s a strategic shift in how your organization connects with constituents. Think of it like stepping onto the field for a high-stakes match: success requires preparation, agility, and a game plan that puts constituent experience at the center. 

At BerryDunn, we’ve helped organizations navigate CRM transformations from kickoff to post-launch refinement. The difference between a CRM that drives loyalty and one that fizzles out? It’s all about alignment, execution, and continuous engagement. 

Building your CRM game plan 

• Start with clarity: Begin with clarity—define your constituent engagement goals, map out existing pain points, and bring stakeholders into alignment early. 
• Implement with intention: Implementation is a team sport—procurement, configuration, and change management need clear roles, flexible tactics, and a shared commitment to customer-centricity. 
• Keep improving: Your CRM journey doesn’t end at launch. Monitor engagement metrics, support your teams with ongoing training, and refine workflows based on real constituent feedback. 

Field-tested insights for successful CRM implementations

A well-designed CRM can transform scattered constituent data into actionable insights that fuel personalized experiences. Because constituent information is usually spread across multiple platforms, without a centralized view, it’s difficult to understand constituent behavior or respond proactively to issues. CRM bridges these gaps by consolidating data into a single source of truth. 

Neutral, strategic guidance helps you avoid vendor bias and stay focused on what matters: meaningful engagement. Don’t fall for the promise of AI chatbots that will answer all constituent questions. Stay focused on how the solution meets and maps to your organizational needs, interoperates with your existing system, and provides better data visibility to empower employees  

Success grows with phased rollouts, tailored training, and processes that scale with your organization’s increased capacity and capabilities. A phased approach allows the focus to remain on high-impact use cases first, and once the intake and response for urgent cases is optimized, gathering additional feedback and refining workflows to further expanding system capabilities becomes an iterative process. It also minimizes disruption by aligning rollout with staff readiness and operational priorities.    

Keys to winning in the long term 

In our experience helping local governments plan, implement, and optimize, successful CRM implementations follow these guidelines:  

• Leadership drives adoption—your team needs active champions, not just a project manager. 
• Technology isn’t a cure-all—a sleek interface won’t fix broken constituent journeys. 
• Strategy comes first—features should follow vision, not the other way around. 
• Experience is valuable—veteran insight transforms complexity into clarity-guiding teams and anticipating hurdles 

How BerryDunn can help 

CRM success is more than software, it’s about building trust, empowering personnel, informing operations, and creating lasting customer relationships. Whether you’re just starting out or refining your approach, the right strategy can turn your CRM into a powerhouse for engagement. 

Ready to build your CRM playbook? Let’s talk about how our vendor-neutral approach can help you connect with constituent in smarter, more sustainable ways. 

BerryDunn is not affiliated with any specific software vendor, allowing us to be truly objective. We stay abreast of the best solutions in the market, as well as industry best practices, emerging trends, and updates in the software vendor community. Our independence allows us to provide objective system consulting services and offer recommendations that serve your organization’s best interests. Learn more about our local government services and team.  
   

Patient care is built on trust—and that trust can be compromised when financial relationships aren’t transparent. That’s why compliance laws like the Anti-Kickback Statute (AKS), the Sunshine Act, and the Open Payments Program (OPP) exist. They are designed to promote transparency in healthcare. This article breaks down the essentials and explores what the laws mean for healthcare organizations and clinicians. 

The AKS: Why free isn’t always free  

Imagine this: A medical device company offers a clinician an all-expenses-paid trip to a conference in Maui. Sounds great, right? Under AKS, it could be a felony. 

What the AKS says 

According to the AKS, it’s illegal to offer, solicit, or receive anything of value to influence referrals for services covered by federal healthcare programs. 

Real-world example: 

A physician accepts lavish dinners from a pharmaceutical representative and then prescribes that company’s drug more often. That’s a red flag under AKS. 

The penalties for convictions under the AKS are up to $100,000 per violation, 10 years in prison, and exclusion from Medicare/Medicaid. 

The Sunshine Act and OPP: Shining a light on industry relationships 

The Sunshine Act, enacted in 2010 as part of the Affordable Care Act, created the Open Payments Program (OPP) to make financial relationships between healthcare providers and the industry more transparent. 

How the Sunshine Act and OPP work 

Manufacturers of drugs, devices, and biologics report payments or transfers of value to physicians and teaching hospitals. CMS publishes OPP data annually, and anyone can look it up.  

Real-world example: 

A clinician attends a dinner sponsored by a medical device manufacturing company. That $150 meal? It’s reported and will appear in the Open Payments database for anyone to see. 

In 2024, CMS reported $13.18 billion in disclosed payments made to clinicians and hospitals, including general payments, research payments, and ownership or investment interests. Patients, journalists, and regulators review this data—so accuracy and transparency are critical. California now requires physicians to inform new patients about reviewing provider data in the OPP.

Key dates for the Sunshine Act and OPP: 

• Data is collected year-round and submitted annually between February 1 and March 31. 
• Covered recipients can review and dispute reported data between April 1 and May 30. 
• Data for the preceding year is published by June 30 and then made publicly available. 

Practical tips for healthcare organizations:

• Develop organizational policies: Many hospitals and healthcare organizations have ethical guidelines and policies surrounding the acceptance of gifts and other remuneration. 
• Educate your team: Share basics with new staff as part of orientation and provide education regarding organizational policies, reporting limits, and how to review and dispute Open Payments data. 
• Review annually: Ensure compliance by reviewing data reported under your institution yearly. 

Practical tips for clinicians:

• Familiarize yourself with policies: Know your organization's ethics guidelines and gifts policies. 
• Learn how to review data reported under your name:
  • Check your OPP profile: Review your Open Payments data annually between April 1 and May 15 to ensure accuracy and dispute any reported data, if necessary.  
  • Ask before you accept: If it feels like a reward, ask yourself, Would I do this if there were no gift involved? If unsure, consult your organization’s compliance department.

Why transparency matters 

Compliance isn’t about saying no to everything—it’s about making informed decisions that protect patients and your reputation. A “gift horse” might look appealing, but if it compromises trust and reputation, it’s not worth the ride. 

BerryDunn can help 

Our healthcare compliance team incorporates deep, hands-on knowledge with industry best practices to help your organization manage compliance and revenue integrity risks. Learn more about BerryDunn’s team and services.   

Additional resources on healthcare transparency laws 

• 42 C.F.R § 403.902 (definitions) 
• 42 C.F.R Section 403.906 (reports of physician ownership and investment interests) 
• American Medical Association, physician transparency reports (Sunshine Act) 
• US Department of Health and Human Services, Office of Inspector General (OIG), “Special Fraud Alert: Speaker Programs”, November 16, 2020 
• CMS Medical booklet, “Medicare Fraud & Abuse: Prevent, Detect, Report  
• OIG guidance on overall compliance education for physicians 

In small towns and rural communities, parks and recreation spaces are vital to quality of life. They’re where neighbors connect, children play, and local traditions thrive. Yet, developing a master plan for these spaces can feel overwhelming—especially with limited budgets and staff. The good news is that effective planning doesn’t have to be complicated or costly. With a right-sized approach, small communities can create practical, actionable master plans that reflect their unique needs and aspirations. 

Learn from real-world success 

Across the country, small communities are proving that right-sized planning works. The most successful efforts share common traits: 

• A clear, shared vision. 
• Strong community engagement. 
• Practical, phased implementation. 

These communities don’t try to do everything at once. Instead, they focus on what matters most, build momentum with early successes, and adapt as they go. 

Let’s break it down: 

1. Build a shared vision for your community, with your community

A compelling vision is the foundation of any master plan. This vision should capture the hopes and dreams of the community, not just the preferences of a few. 

To build this vision: 

• Learn about your community's demographics, existing facilities, and unique character. 
• Engage residents, staff, and local leaders in open conversations. 
• Host visioning workshops to gather ideas and priorities. 
• Draft a vision statement and set strategic, measurable goals. 
• Validate your vision with the community to ensure broad support. 

2. Take stock: inventory and level of service 

Understanding what you have is just as important as knowing what you want. Conduct a thorough inventory of parks, trails, and amenities, and analyze how well they serve the community. 

Key steps include: 

• Mapping all facilities and amenities. 
• Assessing access and quality using level of service (LOS) analysis. 
• Identifying underserved neighborhoods or groups. 
• Visualizing gaps and opportunities for improvement. 

3. Engage the community creatively 

Community engagement is the heart of right-sized planning. Small communities may lack big budgets, but they have strong relationships and local knowledge. 

Effective engagement strategies: 

• Meet people where they are—at markets, festivals, or parks. 
• Use pop-up booths and intercept surveys for informal feedback. 
• Form advisory groups representing diverse interests. 
• Leverage existing community events to reach more residents. 
• Use digital tools like online surveys and interactive maps for broader input. 
• A mixed-method approach ensures everyone has a voice, from youth to seniors. 

4. Conduct a needs assessment 

A thoughtful needs assessment combines data with lived experience. This process uncovers what’s working, what’s missing, and what could be improved. 

Best practices: 

• Collect quantitative data (surveys, usage stats, demographics). 
• Gather qualitative insights (focus groups, interviews). 
• Pay special attention to underserved groups. 
• Compare current offerings with community desires to identify clear priorities. 

5. Prioritize and implement your master plan strategically 

Not every idea can be implemented at once. Prioritization ensures resources are used effectively and progress is visible. 

How to prioritize: 

• Focus on actionable, high-impact projects rather than long wish lists. 
• Break large projects into manageable phases. 
• Match available resources—funding, staff, partnerships—to your goals. 
• Collaborate with local schools, nonprofits, and neighboring communities. 

A helpful tool is the urgency-versus-feasibility matrix: 

Here's an example of how an urgency/feasibility matrix may look:

Right-sized planning empowers small communities to create parks and recreation master plans that are practical, inclusive, and achievable. By clarifying your purpose, building a shared vision, assessing needs, and prioritizing action, even the smallest community can create parks and recreation spaces that enrich lives for generations to come. 

BerryDunn's consultants work with you to improve operations, drive innovation, identify improvements to services based on community need, and elevate your brand and image―all from the perspective of our team’s combined 100 years of hands-on experience. We provide practical park solutions, recreation expertise, and library consulting. Learn more about our team and services.