BDO USA, LLP, a Delaware limited liability partnership, is the U.S. member of BDO International Limited, a UK company limited by guarantee, and forms part of the international BDO network of independent member firms. The New World of Revenue Recognition, ASC 606 – COMPLEXITIES FOR LONG-TERM CARE June 27, 2018
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BDO USA, LLP, a Delaware limited liability partnership, is the U.S. member of BDO International Limited, a UK
company limited by guarantee, and forms part of the international BDO network of independent member firms.
The New World of Revenue
Recognition, ASC 606 –
COMPLEXITIES FOR
LONG-TERM CARE
June 27, 2018
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Example 3—Performance Obligations – Skilled Nursing Facility Services
Traditional Skilled Nursing Facility (TSNF) provides nursing home care to Resident A. As part of Resident A’s care, TSNF provides on a daily
basis, room and board, administration of medications, program activities and on certain days, in-house physical therapy services. The length of
Resident A’s stay at TSNF is not determinable as the date of discharge is based on patient progress; however the contract with the patient is for
a 30 day period, with automatic renewal unless one of the parties provides notice of termination. While the contract is for 30 days, Resident A may
terminate the contract on a daily basis with no penalty for termination. The amount billed for the services described are based on a daily rate to be
paid by Resident A, or its third-party payor based on the actual days for which care is provided.
TSNF considered if the room provided to the resident includes a lease component. That is, TSNF assesses if control of the identified asset (the room)
transfers to Resident A for a specified period of time. If a lease component is identified, that component would be accounted for in accordance with
FASB ASC 840 or 842, and any non-lease components would be accounted for in accordance with FASB ASC 606.
In this case, TSNF concludes there is not a lease of the patient room to the resident.
Although Resident A could benefit from some of the individual goods or services (for example, room, meals, drugs) provided as part of the
individual plan of care (that is, some of the individual goods or services are capable of being distinct), the nature of TSNF’s promise to Resident
A is to transfer a combined item (skilled nursing facility services) to which the promised goods or services noted above are inputs.
Long-Term Care Facilities – Inpatient Services –
Step 2 – Identify the Performance Obligation
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TSNF is responsible for the overall provision of care, which includes identifying goods or services to be provided, including how much skilled
nursing care is necessary, which drugs to administer, and how long Resident A will need to stay in the facility and require a room, meals, and
supplies.
TSNF concludes that each day that Resident A receives services represents a separate contract and performance obligation based on the fact
that Resident A has the unilateral right to terminate the contract after each day with no penalty or compensation due. If a contract can be
terminated by either party at any time without compensating the other party for the termination (that is, other than paying amounts due as a result
of goods or services transferred up to the termination date), the duration of the contract does not extend beyond the goods or services already
transferred. That is the case whether or not the contract has a specified contract period.
TSNF determined that the daily renewal is an option in which there is not a material right as the price of the renewal is a price consistent with the
price for the initial day (that is, there is no discount for the renewal). As a result, TSNF would account for the renewal (that is, each day) when
exercised by Resident A.
While at TSNF, Resident A requested that TSNF provide her transportation services to her physician’s office. Transportation for this type of
request is not covered by TSNF in its normal routine of care and is a service the facility provides to its residents requiring an additional fee
based on miles driven and the type of vehicle required for the transport.
This transportation service for Resident A is capable of being distinct from the standard goods and services provided in the contract and is not
a service that is provided in similar increments on a regular basis as part of the care contract with Resident A. Resident A could also purchase
this service from other service providers and TSNF does not provide a discount on the transportation services. TSNF concluded that the
transportation service provided by TSNF is a separate performance obligation that should be recognized as revenue as the service is provided.
Because the patient simultaneously received and consumed the benefits of the services provided by TSNF in accordance with FASB ASC 606-10-25-
27(a), TSNF concluded that the revenue should be recognized over time.
Long-Term Care Facilities – Inpatient Services –
Step 2 – Identify the Performance Obligation
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The transaction price is the amount of consideration to
which an entity expects to be entitled in exchange for
transferring promised goods or services to a customer.
This excludes amounts collected on behalf of third
parties (e.g., sales taxes etc.).
Long-Term Care Facilities – Inpatient Services –
Step 3 – Determine the Transaction Price
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• Self Pay Patients
• Commercially Insured Patients― Contracted versus non-contracted
• Third Party Settlements and Risk Sharing
Long-Term Care Facilities – Inpatient Services –
Step 3 – Determine the Transaction Price
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Self-Pay Patients
• Price concessions versus impairment losses (i.e. contractual allowance versus
bad debt)
― Implicit price concession versus acceptance of credit risk
― Factors to consider (if either one is met an implicit concession exists):
― Customary business practice of not performing a credit assessment prior to providing services
― Continuing to provide services to a patient (or patient class) even when historical experience indicates that
it is not probable full payment will be received
• When the expectation is to accept a lower amount of consideration, the
promised consideration is variable and therefore a price concession exists
• BAD DEBT EXPENSE…….BELOW THE LINE
Long-Term Care Facilities – Inpatient Services –
Step 3 – Determine the Transaction Price
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Self-Pay Patients - Implicit Price Concessions
• Transaction price should be appropriately constrained― Calculation of price concession should result in an estimate of cash collections at which is
probable that the cumulative amount of revenue recognized would not result in a significant
revenue reversal
• Factors to consider― Current economic conditions in the local market
― Historical experience with similar patients or classes of patients
― Length of collection period
― Standard practices of offering discounts (uninsured, prompt-pay, etc.)
― Historical range of collection history (i.e. significant changes in collection patterns from period
to period)
Long-Term Care Facilities – Inpatient Services –
Step 3 – Determine the Transaction Price
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Commercially Insured - Contracted vs Non-Contracted
• For contracted insurers, consideration will be determined through the
contract with the insurer
• Non-contracted insurers – expected reimbursement is variable consideration― Recognition would likely be similar to that under current GAAP; however, the estimation
process needs to be reviewed to ensure that all elements in the new standard (including
applying the constraint) are considered and conclusions documented (see discussion of portfolio
or individual approach previously)
― Expected reimbursement needs to be reassessed every reporting period
Long-Term Care Facilities – Inpatient Services –
Step 3 – Determine the Transaction Price
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Third Party Settlement Estimates - Contracted vs Non-Contracted
• Amounts reimbursed under government programs (e.g. Medicare, Medicaid)― Subject to complex rules and regulations
― Subject to retrospective adjustments
― Can take several years to finalize
• Revenue from patients covered under government programs will typically
have variable element
• Two methods available: Expected Value and Most Likely Amount― Should use best predictor
― Not intended to be a “free choice” and should be applied consistently
Long-Term Care Facilities – Inpatient Services –
Step 3 – Determine the Transaction Price
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Third Party Settlement Estimates
• Expected Value― The sum of the probability weighted amounts for a range of possible outcomes
― Generally appropriate where there are a large number of contracts with similar characteristics
• Most Likely Amount― The single most likely amount of a possible range of outcomes
― Generally appropriate when only two possible outcomes
― However, ASC 606 does not limit the Most Likely Amount to only two possible outcomes
― May be appropriate for third party settlements even though the outcome is not binary if it leads
to a better predictive estimate
Long-Term Care Facilities – Inpatient Services –
Step 3 – Determine the Transaction Price
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Third Party Settlement Estimates
• Estimate of variable consideration should consider the following:― Historical and current reimbursement information
― Historical and current experience with the fiscal intermediary
― Current charges, allowable costs, and patient statistics
• Method selected (expected value or most likely amount) needs to be applied
consistently
Long-Term Care Facilities – Inpatient Services –
Step 3 – Determine the Transaction Price
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Third Party Settlement Estimates
Reassessment of Variable Consideration
• Differences between original estimate and subsequent revisions are changes
in the estimate of variable consideration― Accounted for as adjustments to revenue in the period of revision
― Should disclose these differences in the financial statements
― Differences not considered to be restatements unless they meet the definition of an error
Significant Financing Component
• Typically not present with third party settlements
Long-Term Care Facilities – Inpatient Services –
Step 3 – Determine the Transaction Price
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Long-Term Care Facilities – Inpatient Services –
Step 4 – Allocate the Transaction Price to the
Performance Obligations
Not applicable! Allocation is not necessary as there is only
one performance obligation.
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Long-Term Care Facilities – Inpatient Services –
Step 5 – Recognize Revenue
Revenue is recognized as/when an entity satisfies each performance
obligation.
Satisfaction occurs as/when the entity transfers control (the ability to direct the
use of and obtain substantially all of the remaining benefits from an asset, or
prevent others from doing so) of the goods or services to the customer.
Revenue is recognized either:
• The customer simultaneously receives and consumes all of the benefits provided by the entity’s as the entity performs;
• The asset that is created or enhanced is controlled by the customer;
• The entity’s performance does not create an asset with an alternative use to the entity AND there is an enforceable right to payment for performance completed to date.
(i) Over time, when the following criteria are met:
• If the criteria for recognition over time under ASC 606 are not met.
(ii) At a point in time:
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Long-Term Care Facilities – Inpatient Services –
Step 5 – Recognize Revenue
• Long-Term Care Facilities satisfy the delivery of inpatient healthcare services
performance obligation over time
• Certain ancillary services (barber, beauty) are recognized at a point in time
once the service has been rendered
• Ensure all conditions are met and no future performance obligations exist
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Long-Term Care Facilities – Other Revenue Streams
Certain Long-Term Care groups have other revenue streams.
• Rehabilitation Services
• Respiratory Therapy
• Occupational Therapy
• Physical Therapy
• Staffing Services
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Long-Term Care Facilities – Other Revenue Streams
Rehabilitation Services:
• Typically two types of contracts:
• Contract bill: facility group contracts with a third party health care provider
to provide services to their patients at pre-determined rates
• Direct bill – facility group contracts with patient directly to provide services
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Long-Term Care Facilities – Other Revenue Streams
Staffing Services
• Customer is typically other non-related facilities who enter into a contract
for Qualified Healthcare Professionals (QHPs)
• Rates are usually set by the hour per position (RN, LPN, CNA)
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Presentation and Disclosures
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Presentation & DisclosureQualitative and quantitative disclosures include:
i. Contracts with customers
ii. Significant judgments in the application of the guidance
iii. Assets recognized from the costs to obtain or fulfill a contract with a
customer
iv. Use of practical expedients.
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Contracts with Customers
• Disaggregation of revenue, including amounts due from third-party payors
related to retroactive adjustments
• Information about an entity’s contract assets and contract liabilities (including
reconciliations)
• Information about the entity’s performance obligations
• The entity’s remaining performance obligations at the end of the reporting
period (not typically applicable for Long-Term Care Facilities)
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Contracts with Customers
Disaggregation of revenue
606-10-50-5 – “An entity shall disaggregate revenue recognized from contracts
with customers into categories that depict how the nature, amount, timing and
uncertainty of revenue and cash flows are affected by economic factors.”
• Payor Type
• Operating Segment / Service line
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Contracts with Customers
Required disclosure information about an entity’s contract assets and contract
liabilities:
• Opening and closing balances of receivables, contract assets, and liabilities
• Reconciliation of significant changes in contract asset or liability balances
during the reporting period
• Amounts due from 3rd party payors for retroactive adjustments (such as final
settlements or appeals) are reported separately on the balance sheet
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Contracts with Customers
Information about the entity’s performance obligations
• When are the obligations satisfied?
• What are the payment terms?
• What is the nature of the goods and services the entity has promised to
transfer?
• Are there obligations for returns, refunds?
• Are there any types of warranties and related obligations?
• Revenue recognized in the reporting period from obligations satisfied, either
completely or partially, in a prior period.
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Significant Judgments and Estimates
A facility shall disclose the judgments, and changes in judgements, made in
applying the guidance, particularly to the following:
― Determining the timing of satisfaction of performance obligations
― Determining the transaction price and amounts allocated to performance obligations
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Assets Recognized from the Costs to Obtain or
Fulfill a Contract with a Customer
A facility shall disclose the following related to capitalized costs to obtain or
fulfill a contract:
― Judgments made in determining the amount of costs incurred to obtain or fulfil a contract with
a customer
― Method used to determine the amortization for each reporting period
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Use of Practical Expedients
Facilities will need to disclose its policy for electing either of the following:
• Existence of significant financing component
• Incremental costs of obtaining a contract
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through more than 60 offices and over 500 independent alliance firm locations nationwide. As an independent Member Firm of BDO International Limited, BDO serves multi-national
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BDO USA, LLP, a Delaware limited liability partnership, is the U.S. member of BDO International Limited, a UK company limited by guarantee, and forms part of the international
BDO network of independent member firms. BDO is the brand name for the BDO network and for each of the BDO Member Firms.
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Material discussed in this publication is meant to provide general information and should not be acted on without professional advice tailored to individual needs.