< PreviousA PROFESSIONAL DEVELOPMENT JOURNAL for the CONSULTING DISCIPLINES 40 SEPTEMBER | OCTOBER 2020 t h e v a l u e e x a m i n e r beneficiaries).104 Nevertheless, long-term nursing care (100+ days) is not covered by Medicare and is primarily reimbursed by Medicaid, the patient, or the patient’s private insurance.105 The care provided at a long-term nursing facility is less intensive than at an SNF.106 Despite some reimbursement from Medicaid, approximately half of all nursing home residents self-pay.107 Once a patient’s savings and resources are exhausted, the patient is then eligible for Medicaid, which in some states may reimburse for long-term care.108 While Medicaid eligibility varies significantly from state to state,109 the average patient must typically have assets valued under $2,000 and monthly income under $2,313 to qualify.110 While Medicaid is unlikely to pay for a separate room for patients in long-term nursing care unless there is a medical need, some states allow for “family supplementation” to enable the patient to have a separate room.111 Medicaid reimbursement rates can vary depending on the state, but on average, Medicaid reimburses at 70 percent of private payors.112 In 2019, the average cost of a shared room was $90,155 annually or $247 per day.113 There is considerable variation based on geographic location, with shared rooms ranging from $150 per day to well over $1,000.114 Hospice Care Facilities As discussed above, hospice care is palliative, end-of-life care. Due to the demographics of individuals (mainly seniors) requiring end-of-life care, 90 percent of hospice industry revenue is derived from Medicare (which will reimburse hospice charges if the patient has been certified by a physician as having less than six months to live115) or Medicaid.116 Given the heavy reliance on government reimbursement, any change in reimbursement by Medicare can have profound effects on hospice profit margins; these margins, which were 10.1 percent in 2017, are expected to rise to 10.7 percent by 2024.117 Recent declines are partly due to reductions in the 104 Diment, “IBISWorld Industry Report 62311,” 5 (see n. 87). 105 FamilyAssets Group LLC, March 8, 2018. 106 “Skilled Nursing Facility Services,” 223. 107 Diment, “IBISWorld Industry Report 62311,” 18. 108 Ibid. 109 “Nursing Home Costs by State and Region—2019,” American Council on Aging, updated October 24, 2019, org/nursing-home-costs. 110 Ibid. 111 Ibid. 112 Ibid. 113 “Cost of Care Survey 2019” (see n. 59). 114 “Nursing Home Costs by State and Region—2019.” 115 “What is Hospice?” (see n. 42). 116 Curran, “IBISWorld Industry Report 0D4952,” 5 (see n. 40). 117 Curran, “IBISWorld Industry Report 0D4952,” 7. annual Medicare payment update; in 2014, CMS established a quality reporting program, which reduced by 2 percent a noncompliant hospice’s reimbursement.118 Further, the annual updates to the Medicare payment rate, which are based on the inpatient hospital market basket update, are reduced by a multifactor productivity adjustment, as required by the Patient Protection and Affordable Care Act (ACA).119 There are four levels of hospice care, each of which garners a different base rate (see Table 1).120 Additionally, Medicare imposes limits (hospice caps) on the total amount of annual payments that a hospice provider can receive for specific services and in the aggregate.121 There are two hospice caps—the inpatient cap and the aggregate cap.122 The inpatient cap is calculated as a percentage of all hospice days that were provided as inpatient days through a specific period.123 It limits the number of inpatient days for which a hospice provider can provide services.124 Once the cap is exceeded, inpatient days are paid at the lower routine home care (RHC) rate.125 However, most hospice providers do not exceed the inpatient cap limit.126 The aggregate cap limits the total payments that may be received in a year in the aggregate for an entire patient population.127 Medicare multiplies the aggregate cap by the total number of patients, and if that number is lower than the actual amount paid to the hospice provider, then repayment is necessary.128 For 2021, CMS has set the aggregate cap to $30,683.93.129 In 2017, 14 percent of hospices exceeded the aggregate cap and were forced to repay the excess amount to Medicare.130 118 “Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer for FY 2020,” Medicare Learning Network, Centers for Medicare & Medicaid Services, August 20, 2019, cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/downloads/MM11411.pdf. 119 Ibid. 120 “Hospice Services,” chap. 12 in March 2020 Report to the Congress: Medicare Payment Policy” (Washington, D.C.: Medicare Payment Advisory Commission, 2020), 121 Ibid., 326. 122 “Update to Hospice Payment Rates,” 3. 123 Ibid. 124 “Hospice Services,” 331 (see n. 121). 125 Ibid. 126 Ibid. 127 Ibid., 326. 128 Ibid., 332. 129 Medicare Program; FY 2021 Hospice Wage Index and Payment Rate Update, 85 Fed. Reg. 47,086 (Aug. 4, pkg/FR-2020-08-04/pdf/2020-16991.pdf. 130 Ibid., 47,084.A PROFESSIONAL DEVELOPMENT JOURNAL for the CONSULTING DISCIPLINES t h e v a l u e e x a m i n e r SEPTEMBER | OCTOBER 2020 41 Table 1: Four Levels of Hospice Care CategoryDescription2021 Base Rate Routine Home Care (RHC) Home care provided days 1-60 Home care provided days 61+ $199.25 $157.49 Continuous Home Care (CHC)Home care provided during a patient crisis $1,432.41 (Hourly rate: $59.68) Inpatient Respite Care (IRC) Inpatient care for a short period to provide respite for a caregiver $461.09 General Inpatient Care (GIC) Inpatient care to treat symptoms that cannot be managed in other settings $1,045.66 Future Reimbursement Trends The variation in senior healthcare delivery is likely to persist well into the future, driven by the differing needs of patients. Further, government reimbursement for these services may be forced to expand as seniors become an increasingly significant segment of the population. Senior care models that can scale to different income levels and reimbursement methods will likely be well positioned for future changes. Conclusion The demand for senior services is expected to increase. The number of Americans ages 65 and older will nearly double from 52 million in 2018 to 95 million in 2060, comprising 23 percent of the U.S. population.131 Not only is the U.S. population expected to shift to comprise a larger cohort of seniors, but these individuals are also expected to live longer, with the average life expectancy in the U.S. currently at 78.7 years.132 Consequently, senior care will undoubtedly play an increasingly important role in the U.S. healthcare industry going forward. Part II of this series will discuss the senior healthcare industry’s regulatory environment, and Part III will discuss the industry’s competitive environment and technological advancements that affect senior healthcare services and organizations. 131 “Fact Sheet: Aging in the United States,” Population Reference Bureau, July 15, 132 Most recent data as of 2018. “Mortality Data,” National Center for Health Statistics, Centers for Disease Control and Prevention, accessed March 3, 2020, Todd A. Zigrang, MBA, MHA, FACHE, CVA, ASA, is president of Health Capital Consultants, where he focuses on the areas of valuation and financial analysis for hospitals and other healthcare enterprises. Mr. Zigrang has significant physician-integration and financial analysis experience and has participated in the development of a physician owned, multispecialty management service organization and networks involving a wide range of specialties, physician owned hospitals, as well as several limited liability companies for acquiring acute care and specialty hospitals, ASCs, and other ancillary facilities. Email: Jessica L. Bailey-Wheaton, Esq., serves as vice president and general counsel of Health Capital Consultants, where she conducts project management and consulting services related to the impact of both federal and state regulations on healthcare exempt organization transactions, and provides research services necessary to support certified opinions of value related to the fair market value and commercial reasonableness of transactions related to healthcare enterprises, assets, and services. Email: jbailey@ healthcapital.com. VEA PROFESSIONAL DEVELOPMENT JOURNAL for the CONSULTING DISCIPLINES 42 SEPTEMBER | OCTOBER 2020 t h e v a l u e e x a m i n e r I hope you enjoyed the July/August interview with Nick Mears. Our interview series continues, with this issue featuring Chris Leventis. Snapshot: My credentials: MAcc, CPA, CVA, CMA, CFE I’m located in: Columbia, SC On my own since: August 2018 Name of my firm: Leventis Financial, LLC My practice sweet spot is: Litigation support in family law matters Typical size company I deal with: $15 million in net assets Rod: So, the BVFLS profession isn’t exactly a calling. Tell us about your background and how you got to where you are today. Chris: I have worked at accounting firms both large and small…and also launched a startup company during grad school in 2015. One of the accounting firms I worked for did some litigation support/business valuation work and, fortunately, I got to see an interesting case. After that, I immediately fell for the work and knew I would get into that world when the timing was right. The startup company was a mobile application, Woozle, that proved to be a daunting task given my lack of software engineering expertise, but it instilled the entrepreneurial bug in me. In short, the passion Woozle left me with for owning/growing a business coupled with my love for the litigation support/business valuation work got me to where I am today. Rod: What was your first year like, and what would have made it better? Chris: Wild!! To ensure that I was prepared when my first case came in the door, I read countless books, took numerous CPE courses through NACVA, and became best friends with Google. Luckily, I love every minute of every day and do not view what I do as work, so it was and still is easy to put in the hours that I do. I was hired on my first case in September 2018 (one month after going solo) and felt like I was drinking from a fire hydrant for almost all of 2019. Honestly, I do not think anything could have made it better. I felt like my back was constantly against a wall and in hindsight I am grateful for that because it forced me to learn at a very quick pace. Rod: Do you have a formal (or even semiformal) business plan? Chris: I do not have a formal business plan and do not plan on making one. However, I do have a task list designed for growth that has similar components to a business plan. As an example, I am starting to do some marketing and have outlined different action items that are designed to accomplish my specific marketing goal, which is to grow beyond the state of South Carolina by the end of this year. I have found that I am much more effective and efficient when I use a process such as this to accomplish any goal. Rod: How did you first attract clients and how did that strategy evolve over time? Chris: I first attracted clients by building a network within the legal community. Whether it is coffee or happy hour, I make a sincere effort to get to know the individual as a Interview: Chris Leventis Chris Leventis PRACTICE MANAGEMENT Practicing Solo “Practicing Solo” features interviews with our industry’s new and seasoned sole practitioners. If you are itching to join the solo ranks, or striving to be more efficient and effective in your established one-person firm, this column offers practical advice, steeped in experience from the trenches, that can move you forward. By Rod P. Burkert, CPA, CVA /////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////// ///////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////A PROFESSIONAL DEVELOPMENT JOURNAL for the CONSULTING DISCIPLINES t h e v a l u e e x a m i n e r SEPTEMBER | OCTOBER 2020 43 person, not just as an attorney. When I get a case, my strategy has been to ensure the clients those attorneys refer to me feel that their case is the most important one in my office and that I am consistently providing them with a great work product. I believe that my growth is directly correlated to this unwavering level of customer service, and it is at the forefront of my plans for the future. Rod: What kinds of engagements did you start with? Chris: I started with litigation support (specifically in family law) and have grown the litigation side of my practice to include both criminal and civil work. However, family law has been my bread and butter. Additionally, I do some business valuation work (approximately six in 2019 and eight so far in 2020). Going forward, I would like to work primarily in litigation and business valuations for estate and gift tax purposes. Rod: Do you practice in a specialized niche today? Chris: I initially thought litigation support and business valuation work was a niche, but I quickly realized how much one can specialize within both of those areas. So, my primary niche is litigation support for family law matters and business valuations for estate and gift tax purposes. Rod: What has been your best marketing tactic? Chris: Primarily word of mouth, but also speaking engagements at different conferences. I personally built the website I had for almost two years but recently had it professionally redone. There is only so much a colorblind accountant can do with web development! Rod: How do you price your work? Chris: For litigation support, I require a retainer up front (between $5,000 and $10,000, dependent upon my scope), and I bill hourly. For business valuations, I require a retainer up front ($2,000 for a calculation of value and $4,000 for a conclusion of value) and bill hourly. Further, with business valuations, I quote a fee range and guarantee my client that I will not exceed the upper threshold. I would love to be able to consistently do something similar with litigation, but my experience with these cases has been that they are usually impossible to predict, thus hindering me from always quoting a fixed price. Most frequently, my scope in litigation is to deal with every financial aspect in the case, not just one piece. However, if I am brought in to do something specific, such as value a pension plan for a divorce case, I do quote a fixed amount as the amount of work needed is completely predictable. Rod: Where do you get your “runner’s high” from: (1) getting the work (e.g., practice development), (2) doing the work (e.g., an intellectually challenging analysis), or (3) delivering the work (e.g., reviewing a report with a client)? Chris: When I first started, I would have said number one, because it validated the risk I took to go on my own. Now that I have a steady flow of projects, I would say number two. I grew up playing sports and constantly competing, so I love figuring out solutions to the challenges that every case or valuation brings. Rod: How do you differentiate yourself from larger firms? Chris: I do not really think about or know what other firms are doing and frankly do not have the time to do so. My focus is on treating my clients with respect, making sure they feel their engagement is the most important one in my office, and doing great work. I believe that if I do this consistently, I will stand out. Rod: Do you work from a home office or an “office” office? Why? Chris: Both, but 95 percent of the time I work from an “office” office. I try to separate my home and work lives, and I have found that I cannot accomplish this without physically separating the two. Rod: What is your current mobile device? Chris: iPhone 11 Pro. Rod: Describe your current computer/workstation set up. Chris: I have an HP desktop with upgraded RAM and hard drive capacity as well as three monitors, which sounds like a lot, but I promise you will never go back! My focus is on treating my clients with respect, making sure they feel their engagement is the most important one in my office, and doing great work.A PROFESSIONAL DEVELOPMENT JOURNAL for the CONSULTING DISCIPLINES 44 SEPTEMBER | OCTOBER 2020 t h e v a l u e e x a m i n e r Rod: Besides your phone and computer, what apps, gadgets, or tools can’t you work without? Chris: Two things: my scanner and my phone system! The scanner is a Fujitsu ScanSnap iX1500, and it works great. And I use the RingCentral VoIP phone system. It is cost-efficient, links directly to my cell phone if need be, and comes with free group meeting features (both virtual and teleconference). Rod: What do you listen to while you work? Chris: I love just about any type of music and listen to it throughout the day. It varies from classic rock to EDM to piano classics. Rod: How do you keep track of what you have to do? Chris: I keep a task list within Excel. It is organized by matter and further filtered by due dates and priority. Rod: What are your best cost-saving ideas? Chris: My best cost-saving ideas are to welcome automation where possible. I would suggest documenting every process for every service offering and determining the areas that can be automated/improved. For instance, I do not have off- the-shelf business valuation software, but I do have macros within Excel and premade spreadsheets that save me hours of work and accomplish the same things that valuation software would. Rod: Early bird or night owl—what’s your sleep routine? Chris: Neither, I am more of a weekend warrior! There are obviously the mornings that I wake up really early and the evenings that I do not sleep much, but I prefer to work 10– 15 hours on the weekends and keep my weekday hours as consistent as I can. Rod: Do you have any office/admin staff? Chris: Currently, I do not have any office or admin staff. This is a role that I am anxious to fill as my workload has gotten to the point where I cannot handle the administrative tasks that come with running a business. Rod: Do you have a support group to call on? Chris: Yes. I have one individual that used to do solely litigation support work before getting into venture capital. He is a great resource because he never has a conflict of interest, and he has worked on cases similar to the vast majority of ones I have in my pipeline. It helps me sleep at night knowing that I have him by my side after I have exhausted all other resources. I highly recommend anyone going out on their own to have someone like this! Rod: How do you stay technically current with changes in the profession? Chris: I read magazines such as The Value Examiner, take targeted continuing education courses, and allocate an additional four to five hours per month for general research in the litigation support/business valuation arenas. Occasionally, I will do a Google search on things such as “accounting” and select “news.” Surprisingly, this has been a great help! [Rod’s note: I suggested to Chris that he automate this process by setting up Google Alerts.] Rod: What non-BVFLS book have you read most recently or want to get to, and why? Chris: Atomic Habits by James Clear. This book put the construct of habits into perspective and was a game changer for me. I highly recommend it. Rod: How do you recharge? What do you do when you want to forget about work? Chris: Travel. I typically work extremely hard for a few months and then travel abroad for about three weeks at a time. I usually do not take work overseas with me (even though I did update a report and wander around downtown Singapore to find a notary in 2019) to allow myself to recharge. Rod: What are the biggest practice CHALLENGES you face as a sole practitioner? Chris: From answering phones to sending out invoices to doing highly complex analyses, wearing every hat in the organization is my biggest challenge. It can be difficult to get to the work that needs to be done when you are interrupted with administrative tasks. Rod: What (or where) are the biggest practice OPPORTUNITIES for someone going solo now? I would suggest documenting every process for every service offering and determining the areas that can be automated/improved. A PROFESSIONAL DEVELOPMENT JOURNAL for the CONSULTING DISCIPLINES t h e v a l u e e x a m i n e r SEPTEMBER | OCTOBER 2020 45 Chris: I think there is a lot of room in the consulting arenas, but I also think there is a market for my generation to offer general accounting services. Individuals in their 20s and early 30s are starting businesses and doing other things where they need CPAs. And I believe that can be leveraged to start and grow a firm at a young age! Rod: What is the best work/life advice you have ever received? Chris: Someone once told me to think about the construct of work/life balance. We always place work before our lives. I lost my brother in 2017 and immediately realized how precious life is and how right this individual was. So, I would say that advice of not working so hard that you forget to live is the advice that has stuck with me the most. Rod: Finish this sentence: If I knew then what I know now, I would have… Chris: …made better use of my time. I learned an impossible lesson after the passing of my brother, but the silver lining I gained was a completely new perspective on life. I now know that time is my most valuable asset and that I cannot put off until tomorrow what I can do today because tomorrow is not promised! That’s a wrap! Answers have been lightly edited. Do you have a Practicing Solo issue you would like me to address? Email me Rod P. Burkert, CPA, CVA, works with BVFLS practitioners and firms who have hit a time or income ceiling and want to grow faster and smarter. If you are feeling frustrated by those limitations, email him at Chris uses an HP desktop with upgraded RAM and hard drive capacity as well as three monitors, which, he says, “sounds like a lot, but I promise you will never go back!” I think there is a lot of room in the consulting arenas, but I also think there is a market for my generation to offer general accounting services.The Leader in Valuation Data and Research KeyValueData Platinum, and how spectacular once you do, you will a regular basis, and litigation, M&A, and Feel free to contact consultants if you or any other Sincerely, Parnell Black, MBA, Chief Executive Dear NACVA Member: We Have A Member Benefit You Won’t Believe (Worth Thousands) P.S. 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