A patient survey shows that patients want upfront healthcare cost estimates. Meanwhile, mental health practitioners argue that the new way they're required to issue estimates won't work for their industry.
An overwhelming majority of patients surveyed—89%—say knowing the amount of their healthcare bill and making a payment before their visit would have been an easy way to pay for their most recent medical visit.
Yet, 70% of consumers either didn't receive a cost estimate before their most recent healthcare visit or were unsure about whether they received one.
Those are findings of a survey by PYMNTS, which polled 3,546 adult American consumers about their healthcare payment experiences.
In addition, cost and insurance coverage are key reasons patients didn't seek needed medical care.
The survey found that 33% of consumers have opted out of seeking needed medical care, either by not making necessary healthcare appointments or abandoning needed treatment.
Of those patients, 21% say that cost was the top reason for not getting the care. Another 11% said that they didn't seek or continue care because their health insurance plan would not cover the appointment or treatment.
Insurance coverage also affects where people seek their medical care. The PYMNTS data finds that most patients would switch their current providers if their insurance stopped covering their visits. In addition, 59% said services not being covered was an important reason why they would consider leaving their healthcare provider.
Blanket rules about providing upfront estimates might not work, though.
They say that although their industry already prioritizes sharing cost information with patients, providing the specific kind of "good faith estimates" required under the No Surprises Act places an undue burden on mental health practitioners.
They note, among other things that:
Requiring clinicians to fill out and update the good faith estimate (GFE) form "every time there is a minor change in the treatment plan that may or may not have an impact on costs takes away from valuable treatment time."
The rule "fails to capture the practical nuances involved in referring patients to other independent mental health practitioners for treatment, as well as the urgency under which appointments are scheduled."
Insurers may use the good faith estimates "as a mechanism or justification to limit mental health treatment beyond the scope of the GFE, or otherwise view them as an admission that the patient will only require a certain degree of mental health treatment."
HealthLeaders checked in with revenue cycle leaders and experts across the country to hear about the first few weeks of this landmark rule.
We're just over a month into the implementation of the No Surprises Act (NSA), which protects patients from balance billing but still has a lot of controversy surrounding it, namely around the arbitration method, which providers say unfairly favors payers.
Still implementation and compliance are underway, says Becky Greenfield, a partner with Wolfe Pincavage.
"Our clients are working diligently to comply with all components of the NSA, developing work groups spanning across patient accounts, legal, revenue integrity, managed care, IT, and other departments to identify operational and technical areas that need to be updated to achieve compliance," she says via email.
That's not to say everything will run smoothly as revenue cycles work to comply with all of the rule's requirements and moving parts.
"This is a massive bill to get a handle on," she says. "At the onset, I think there will definitely be some trial and error, especially with respect to the independent dispute resolution process."
There, she says their "clients are in the process of developing workflows and frameworks to ensure claims are timely submitted through the correct dispute resolution procedure."
That "includes identifying out-of-network claims early (and what type of claims they are), assigning certain codes to the claims within their EMR, reviewing EOBs through an expedited process to ensure the quick turn-around times under the federal dispute resolution process are met, batching the right claims together, and getting them to the right internal department or outside vendor once they have been underpaid," she says.
In addition, Greenfield says another issue that will likely come up for revenue cycles as they attempt to comply with the rule is parameters surrounding the notice and consent process, such as when the notice and consent process can be used.
"For example, understanding how the agency defines post-stabilization services and when balance billing prohibitions can be waived," she says.
HealthLeaders checked in with revenue cycle leaders across the country via email and phone to get a temperature check on the first few weeks of this landmark rule. Here's what five of them had to say:
Stephanie Wells, system vice president of revenue cycle/HIM, and Katherine Cardwell, vice president of revenue cycle, for Ochsner Health, Louisiana:
"Ochsner Health knows the pandemic and recent hurricanes [in Louisiana] have brought new difficulties to our patients and communities. While recent changes in federal law aim to protect against 'surprise' or 'balance' medical bills, the law covers practices Ochsner Health already commits to out of care for our patients’ healthcare and financial needs.
Transparency is important to Ochsner especially as our country continues to confront the COVID-19 pandemic. We are committed to helping our patients understand what they can expect to pay for care so they can make informed decisions.
Ochsner's Surprise Billing Disclosure document outlining Patient Rights and Protections Against Surprise Medical Bills is available on our website, is posted in registration areas, and is sent through email along with estimates. It is also offered by our financial call center when employees ask for pre-payment, is presented during e-pre-check of patients, and is offered by registration onsite.
Ochsner has also ensured that self-pay patients who scheduled at least three days in advance will receive an estimate for their care through their patient portal and via email. If electronic methods are not available, Ochsner prints and mails the estimates. Additionally, our scheduling team has scripting to notifying self-pay patients of their right to receive a good faith estimate. At the time of scheduling, we email patients information about patient rights and protections and explain how to obtain an estimate.
Estimates can be received through our self-service, cost estimator tool, which is available online, 24 hours a day, seven days a week at Ochsner.org/Patients-Visitors/Billing-and-Financial-Services. Our dedicated central pricing office is also available to provide patients with in-person assistance for tailored, personalized estimates based on individual circumstances, and our financial services team proactively calls patients and sends a message through the patient portal to inform patients of out-of-pocket costs.
Ochsner believes this regulation to be administratively burdensome and does anticipate there will be tweaks to how the law is implemented to address certain administrative processes for health systems. We will comply as new regulations implementing the No Surprises Act are clarified and come into effect."
Karen Kennedy, director, revenue cycle, Cleveland Clinic, Ohio and Florida:
"Our planning and preparation for implementation of the No Surprises Act (NSA) was led by a cross-functional team including high-functioning caregivers from IT, legal, patient access, billing, self-pay follow-up, and education.
Members of this team met weekly to create an overall strategy and manageable ongoing process that met all of the additional requirements of the NSA by January 1.
Although this implementation was complex and resource intensive, Cleveland Clinic completed its implementation by January 1 and fully supports the legislation to protect patients from surprise billing."
Candice Powers, chief revenue cycle officer, Mon Health System in West Virginia:
"The No Surprises Act has cemented the importance of pre-access services in our facilities. Mon Health will continue to evolve to meet the patient in their healthcare journey with accurate individualized estimates of the services they need.
As an industry, the tools necessary to be compliant with these requirements will also need to evolve. To be fully compliant, healthcare providers, payers, and technology service offerings will need to align quickly. Change is the only thing consistent in the healthcare space."
Sarah Ginnetti, associate vice president of revenue cycle atUConn Health, Connecticut:
"As a result of preparing for that regulation to go into effect on January 1, we did stand up another cross-functional team in the organization. We found a way to develop some workflows within Epic [and] identify the right team members to assign to some of this work in order to manage and respond to the No Surprises Act.
I think we actually have a pretty good process in place. It is very manual and that's the one thing I don't like about it. But we right now don't have the infrastructure set up around it to make it a more automated process. However, that is part of our roadmap going forward that's tied to the patient experience. [That will include] building out our estimate platform.
For all intents and purposes, we are, I would say, 90-plus percent compliant, and were as of January 1."
Although the most senior-level revenue cycle roles are the most difficult to fill, even entry- and mid-level roles present expensive, time-consuming challenges.
It takes an average of 207 days and costs $5,699 to fill vacant senior-level revenue cycle roles, according to a new survey.
AI company AKASA surveyed 514 chief financial officers and revenue cycle leaders at hospitals and health systems across the United States through the Healthcare Financial Management Association's (HFMA) Pulse Survey program.
Although the most senior-level revenue cycle roles—those that require 10 or more years of experience—are the most difficult to fill, even entry- and mid-level roles present expensive, time-consuming challenges.
The survey found that vacant entry-level revenue cycle jobs cost an average of $2,167 for recruitment and take about 84 days to fill. These are the jobs that are the most basic, calling for zero to five years of experience.
Vacant mid-level revenue cycle roles (ones that require 6-10 years of experience) cost an average of $3,581 for recruitment and take 153 days to fill.
The survey also notes that the complete cost to recruit is likely even higher for all these jobs, since revenue cycle leaders might not factor in recruitment costs from other departments, such as marketing and human resources, or other training and onboarding costs.
The "Great Resignation" is hitting all industries, and many revenue cycle leaders are thinking about the future of their departments by implementing succession planning, training programs, and competitive salaries.
For instance, Cassi Birnbaum, senior enterprise director of HIM, coding, and CDI at PeaceHealth in Vancouver, Washington, says, "succession planning needs to begin the day that you enter an organization and … your position."
"It's incumbent upon us as senior leaders to really develop a deep talent pool," she says.
At UC San Diego Health, customer service is the highest-paid revenue cycle position because it's the "face of the patient financial experience," says Terri Meier, director of system patient revenue cycle.
With a higher salary comes "a higher expectation." In addition to receiving formal, ongoing, day-to-day education, these employees also undergo annual competency testing.
Education is also important to Sarah Ginnetti, associate vice president of revenue cycle at UConn Health. Not quite a year into her role there, she's been working to stand up an institutional membership through HFMA.
Doing so will "help educate our staff about all of the nuts and bolts of revenue cycle that sometimes we expect people to just learn through osmosis," she says.
Taking steps to shore up trust, communication, and training before making changes will provide leaders a strong foundation upon which to build improvement initiatives.
When coming into a new leadership role, it's easy for senior revenue cycle leaders to want to jump into action and immediately start trying to correct processes, systems, and workflows.
"A lot of us are eager fixers in the revenue cycle," says Sarah Ginnetti, associate vice president of revenue cycle at UConn Health.
But Ginnetti didn't start trying to fix things right away when she came into her role at UConn in March 2021 after spending nearly 19 years in the revenue cycle at other hospitals in Connecticut. Instead, she asked a lot of questions. And she listened.
Revenue cycle elders "want to get our hands on things, and we want to try to start fixing," she says. "But it's really essential to listen to the folks that are in place."
Only then can new leaders learn about current processes, hear what team members' pain points are, and understand what barriers they're facing.
Such leadership skills will be increasingly important as job turnover skyrockets from the "Great Resignation" and as baby boomers continue to retire. Ginnetti has already faced both staffing situations in her new role, with two directors moving on from the organization and other revenue cycle employees taking advantage of Connecticut's state pension system and opting for retirement.
1. Listen before trying to fix things
In the 10-plus months Ginnetti has been in her new role, she's certainly put new initiatives in place, from improving how the system's claims management logic is set up to taking steps to improve the patient estimate process.
But before Ginnetti started "fixing," she did something else first: Listened, asked questions, and built rapport with the staff.
For example, she advises "spending your first 90 days just listening and not doing much else."
"The first step is to build trust with the team members that are already there. I think that's key," she says. Only then will leaders understand what systems and processes employees are working with and why.
In addition, doing a lot of listening helps leaders build goodwill with team members.
"Then as you start moving your own initiatives forward, they're much more willing to buy into what you're doing and really be a part of it," she says.
2. Ask questions to get to the 'why'
Ginnetti also says that asking a lot of questions is a key element of her leadership style.
"I'm very curious about seeing firsthand what's happening under the hood," she says. And despite her senior leadership role, "I do sometimes dig down into the layers of the work."
Not only does digging into the layers allow Ginnetti stay in touch with and understand the day-to-day work, but it also enables her to ask additional questions about the processes and steps that employees use to complete tasks and identify places for improvement.
For example, if she notices employees are using a lot of workarounds or taking excessive steps to complete certain tasks, she asks the crucial question: Why?
Sometimes she discovers that team members simply have never been shown another way to do something or that no one has ever asked about their process, so they've never had the opportunity to make a positive change.
"I really try to encourage my team members and my leaders to always be thinking critically, asking 'Why' over and over again," she says.
And in asking why, there's one answer Ginnetti will not accept: "Because we've always done that way."
"That may be true. But that doesn't tell me why we're doing it," she says. "I have always come at the work with a lot of curiosity. And I try to cultivate that same curiosity among my team members so that they will adopt a similar mindset if they don't already have it. I believe it becomes an essential steppingstone in terms of how you make progress."
3. Help staff develop their skills
Effective leadership also means helping staff develop their skills, which is why Ginnetti has spent some of her first year partnering with UConn Health's vice president of finance to stand up an institutional membership through HFMA, which they're working on now.
By offering some industry developed, standardized education—they plan to roll out the program later this year—Ginnetti hopes to provide a broader foundation of knowledge among the revenue cycle staff and create a more formalized process for ongoing training, since learning the revenue cycle can be "like learning another language."
Doing so will "help educate our staff about all of the nuts and bolts of revenue cycle that sometimes we expect people to just learn through osmosis," she says.
"The customer service element of the revenue cycle is so critical, and I think it's often the overlooked part of the patient experience," she says.
Taking these steps to shore up trust, communication, and training before swooping into fix-it mode will provide leaders a strong foundation upon which to build improvement initiatives.
"I'm optimistic that we're now stabilizing the leadership team here for the road ahead," she says, "so that we can start moving some of our objectives forward."
Advisories, information sheets, and FAQs aim to help hospitals, health systems, physicians, and consumers understand the new rules against surprise billing.
Despite ongoing legal challenges to parts of the No Surprises Act, key elements of it went into effect on January 1, and stakeholder organizations are responding with guidance for their constituents. In addition, CMS has added new information on its website for consumers.
Here's some of the latest:
The American Hospital Association on Friday published a No Surprises Act legislative advisory that includes a summary of and key takeaways about the law, along with a 15-page detailed summary of the rules.
"The hospital and health system field strongly supports protecting patients from surprise medical bills," the American Hospital Association said in a statement. "We believe this legislation is an important step forward in protecting patients."
In addition, the legislative advisory webpage links to additional resources, including an FAQ for members about the uninsured/self-pay good faith estimate; details about the AHA/AMA lawsuit challenging how federal regulators proposed resolving billing disputes; and information about CMS guidance.
The American Medical Association on Friday published an advocacy update outlining what physicians need to know about the No Surprises Act.
It links to a newly published toolkit that focuses on three key issues for physicians to know about and understand: the notice-and-consent requirements for when out-of-network clinicians provide care at in-network facilities; rules about emergency services and post-stabilization care at hospitals or freestanding emergency departments; and the requirement to provide good faith estimates for self-pay and uninsured patients.
Also on Friday, CMS added online information for consumers explaining that as of January 1, "consumers have new billing protections when getting emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers."
"Through new rules aimed to protect consumers, excessive out-of-pocket costs are restricted, and emergency services must continue to be covered without any prior authorization, and regardless of whether or not a provider or facility is in-network," the website says.
The new page also links to explanatory resources for consumers, including ones that outline what surprise bills are and the new consumer protections that are now in place thanks to the No Surprises Act.
Among the notable deals are R1's acquisition of Cloudmed, nThrive's completed acquisition of TransUnion Healthcare, and AccessOne's CueSquared acquisition.
Acquisitions, partnerships, and expansions continue to be the name of the game in the healthcare world and revenue cycle tech companies that are looking to expand their depth and reach are no exception.
Here are some of the latest:
R1 RCM is acquiring Cloudmed, which serves more than 400 of the largest health systems in the United States, including 47 of the top 50 hospital systems, with its revenue intelligence platform that combines cloud-based data architecture with intelligent automation.
In 2021, Cloudmed said it recovered more than $1.5 billion of underpaid or unidentified revenue for customers, delivering an average client ROI of 3-5 times what they invested.
The combined companies will provide solutions for "both end-to-end revenue cycle management and technology-driven revenue intelligence …[that] unite decades of coding, charging, and reimbursement expertise to drive further client digitization through automation and AI," according to a statement from the companies.
nThrive completed its acquisition of TransUnion Healthcare, the healthcare data and analytics business of TransUnion. The unified business will offer healthcare organizations complete end-to-end RCM technology solutions, according to an announcement about the deal.
Together, they'll combine TransUnion’s social determinants of health data and insurance discovery with nThrive’s claims and contract management; front-end capabilities and workflow for acute and ambulatory providers; and other solutions.
RevSpring is partnering with T-Base Communications to deliver fully accessible consumer engagement, including billing information, across digital and print channels for visually and cognitively impaired patients and consumers, as well as people with auditory requirements.
The healthcare payment company says that adding accessibility tools to its consumer engagement and billing solutions will help people with disabilities better access and understand their healthcare expenses.
T-Base provides accessible communications in various formats including accessible PDF, e-Text, HTML, audio, braille, and reflowed large print. RevSpring will integrate T-Base's accessible PDF, braille, and reflowed large print capabilities into its suite of engagement tools.
AccessOne has acquired CueSquared, a one-touch mobile payment platform that aims to simplify collection for patient self-pay balances.
CueSquared securely engages patients with an individualized, text-based payment solution that eliminates the need for paper statements, apps, or portal logins. As a result, 70% of payments are received within seven days, and providers realize a 50% per-payment reduction of collection expenses, the companies said.
Maximizing efficiency at patient access has helped Goshen Health improve wait times, increase point of service collections, and add value to the overall patient experience.
Sitting in a hospital waiting room isn't a good use of anyone's time.
"I haven't met a patient yet that comes to the hospital to actually be in patient access," says Sue Plank, director of patient access for the nonprofit, community-owned Goshen Health, a health system based in Goshen, Indiana, with 35 locations across four counties. "They are here for another service. So, any time that they spend in patient access is not [a] value-add to them."
By now it's common knowledge that a bad revenue cycle experience can sour an otherwise positive healthcare encounter. But revenue cycles should aim higher than providing patients with an experience that's not "bad" and instead provide one that's easy, efficient, and makes the most of patients' time.
That's why Goshen Health has taken steps to centralize, digitize, and streamline the patient access process to make it easier and quicker for patients to get to their ultimate destination: Their healthcare appointments.
They've done it by adding tools in a phased approach over several months: eligibility verification and payment estimating in August 2020; a payment processor in December 2020; a patient flow tracker in February 2021; appointment reminders and COVID screening in March 2021; and online patient intake in April 2021.
Here are three reasons revenue cycles should make the most of patients' time and aim to add value to their overall healthcare experience.
1. Wait times will 'plummet'
Goshen Health had already taken steps to centralize patient registration and streamline the financial clearance processes by scheduling patient labs, but they were missing a way to digitally communicate with patients prior to their arrival. The pandemic made that need even greater, since they wanted to avoid having patients in the waiting room for too long.
Deploying tools from AccuReg helped to open that two-way communication.
"Our initial goal was simply to be able to engage digitally to be able to register [patients] in advance, but it's given us way more than that," Plank says. For instance, patients can do things like send pictures of their photo ID and insurance cards and digitally sign consent forms.
"That gives us the key elements that we need in order to financially clear them," Plank says.
Patients can choose which digital offerings—including appointment reminders, COVID screening, electronic check-in, and patient intake—they want to engage with. Since implementing it in April, for instance, the online patient intake portion of the tool has about a 40% utilization rate. Utilization of appointment reminders and COVID screening has reached about 65%.
All of this has resulted in combined wait and registration times that have dropped significantly, from between 23 and 30 minutes down to roughly seven minutes.
"Our patients love it," Planks says. "It is such a stark difference from what it was before."
2. Point-of-service collections will increase
Goshen Health didn't change any policies, procedures, or expectations regarding point-of-service collections, yet they're up 45% from its 2019 benchmark.
The reason why is simple: They interfaced a payment processor into the patient access tools that registration staff use.
Previously, registration staffers had to log into two separate systems for patient payments: One to take the payment and another to document it. Now, employees see a button to "pay now" on the same screen as the payment estimate information, which launches them directly into a payment processor. This allows them to collect and automatically electronically document the patient payment.
Seeing the increased collections "honestly was a bit of a surprise," Plank says. When she asked her colleagues why collections were up, they laughed and said, "because it's so easy."
"My learning from that, as a director, is give the right tools to your colleagues," she says. "And they actually will produce the results."
3. Better tracking of no-shows
Prior to implementing the patient tracker, the revenue cycle had trouble keeping track of patient no-shows. EHRs, Plank notes, are "built often for the clinical component and so the revenue cycle side doesn't usually have a lot of bells and whistles."
Now, the patient tracker gives some patient-flow visibility thanks to engagement tools that allow patients to confirm, cancel, or reschedule their appointments.
"That's a benefit to us, obviously, because now we don't have an MRI table sitting empty," she said. "And that certainly allows us to maximize our revenue."
Maryland, New Mexico, Washington, and Nevada are among the states making efforts to help patients out of medical debt.
Thirty-five percent of American adults carry medical debt, according to HealthCare.com, but new state laws are aiming to limit how aggressively—or even whether—hospitals can collect that money.
For instance, on January 1, the Medical Debt Protection Act of 2021 went into effect in Maryland, which prohibits hospitals from putting liens on patients' homes over medical debt and from garnishing wages of patients who qualify for free or reduced-cost care.
The law also requires a state agency to develop guidelines for hospitals to establish income-based payment plans, and until those guidelines are created, hospitals can't sue patients for any medical debt.
Research shows aggressive medical debt collection efforts are on the rise among hospitals. For instance, a new Health Affairs study published in December revealed that in Wisconsin, hospital lawsuits over medical debt increased 37% from 2001 to 2018.
Maryland is only one example of states making efforts to help patients out of medical debt. Others already have or are working on similar measures, including:
New Mexico: The Patients' Debt Collection Protection Act went into effect on July 1, 2021, which prevents healthcare facilities and medical debt collectors from continuing collection actions (including lawsuits and wage garnishment) against low-income patients who earn less than 200% of the federal poverty level (FPL).
It also puts into law some revenue-cycle best practices, requiring healthcare facilities to verify whether the patient has health insurance, screen for all available public insurance and financial assistance, and help patients apply for such programs, before they can collect a bill.
In addition, last month, the state's Office of Superintendent of Insurance issued final medical debt rules that require medical providers and hospitals to check whether a patient has a low income before suing them or sending them to collections and guarantees that a patient with a low income is protected from being sued or sent to collections for two years.
Washington: Patients at the FPL already get their out-of-pocket medical debt forgiven.
House Bill 1616would broaden those protections to patients who exceed the FPL by as much as 300%. Patients who earn 400% above the FPL would be able to get partial write-offs.
Nevada: Nevada's senate bill 248 went into effect July 1, 2021, and includes rules about how collection agencies can go after medical debt. For instance, under the new law, collection agencies must notify patients by certified letter at least 60 days before taking action to collect a medical debt.
The letter needs to include the names of the medical facility and provider, the date of service, and the principal amount of the medical debt, as well as the name of the collection agency.
The volume of prescription opioids dispensed from retail pharmacies declined by 21% from 2008 to 2018, a new study finds.
Although the volume of opioid prescriptions has decreased, the decline varied depending on the location, the kind of patient, and who was doing the prescribing, according to a new RAND Corporation study published by the Annals of Internal Medicine.
The study found that the volume of prescription opioids dispensed from retail pharmacies declined by 21% from 2008 to 2018.
It declined the most in metropolitan counties (more than 22%) and in counties with higher rates of fatal opioid overdoses (a 35% decline).
Among prescribers, the greatest percentage decrease was among emergency physicians (71% decline), who are likely prescribing opioids predominantly to patients experiencing acute pain in acute care settings.
"The findings do not provide concrete answers about how much of the unnecessary prescribing of opioids has been eliminated," Dr. Bradley D. Stein, the study's lead author and a senior physician researcher at RAND, said in a statement. "But the work demonstrates that there is a lot more nuance in the changes in opioid prescribing than we previously understood."
RAND researchers examined differences in opioid prescriptions filled at pharmacies during the periods of 2008 through 2009 and 2017 through 2018. The prescription information came from IQVIA Prescription data, which captures about 90% of prescriptions filled at U.S. retail pharmacies. It's the first study to examine the decline in opioid prescriptions filled at retail pharmacies based on both volume and potency of the drugs dispensed.
They used days' supply and total daily opioid dose to calculate per capita morphine milligram equivalents (MME) for opioid prescriptions filled during the study period. Because opioids are available in different forms, this measurement provides a better assessment of the total amount of opioids filled by patients as compared to just the number of pills dispensed, the researchers said.
The study also found variation both within and across states. In some states, MME volume per capita increased in multiple counties. In many other states, there were counties with both increases and others with substantial decreases. Counties that experienced substantial decreases in per capita MME often were adjacent to counties with per capita increases.
Most clinical specialties recorded declines in the MME volume per practicing clinician. The greatest decrease in MME volume per practicing clinician was among adult primary care physicians (40% decline) and pain specialists (15% decline).
"Future efforts to enhance clinically appropriate opioid prescribing may need to be more clinically nuanced and targeted for specific populations," Stein said.
Price transparency, surprise billing, and a renewed focus on the workforce grabbed much of the focus from revenue cycle leaders during another unprecedented year.
It was another tumultuous year for the revenue cycle, from the slow burn of price transparency and the fight over surprise billing, to the renewed focus on the workforce, not to mention the continuing COVID-19 pandemic.
Here are three issues that defined 2021 for the revenue cycle:
1. Price transparency's slow burn
For all the build-up and fretting over the price transparency rule, it got off a slow start and hasn't sped up much since. Just a few days after the January 1 compliance deadline, Becky Greenfield, a partner with Wolfe Pincavage, told the HealthLeaders Revenue Cycle Podcast that none of the hospitals she had investigated were fully compliant with the rule yet.
Not much changed as the year progressed. In February, a Guidehouse analysis found that roughly 30% of hospitals weren't compliant with either requirement of the CMS price transparency rule, and only 48% of hospitals were compliant with at least one element of the machine-readable file requirement.
By June, research published in JAMA Internal Medicine confirmed what had been anecdotally reported for months: That hospitals are choosing which parts of the rule to comply with, and that partial compliance is common.
By late fall, though, there were indications that noncompliant hospitals might not be able to skate by forever. CMS said in its final Outpatient Prospective Payment System (OPPS) rule for 2022 that the fines are going up. It said it will set a minimum civil monetary penalty of $300 per day for hospitals with 30 or fewer beds. Hospitals with more than 30 beds will be charged $10 per bed per day, which will cap at $5,500 daily, and the maximum total penalty amount would be $2,007,500 per hospital.
Eric D. Hargan, former deputy secretary of the U.S. Department of Health and Human Services, told HealthLeaders that the fact that two polar-opposite presidential administrations support price transparency is a good indication that it's not going away.
Plus, he noted that the government may keep raising fines until it gets compliance. Moreover, hospitals that make a good-faith effort to comply will have credibility when it comes to showing the government which parts of the rule need to be changed.
"It's the people that recognize the shape of things to come and help participate in it … who will have a chance to shape what goes forward," Hargan said.
2. Surprise billing heats up
We're only days away from surprise billing's first enforcement deadline, but the fight over it is far from over.
The government said relatively early in the year that it would be using final-offer, or "baseball-style," arbitration to settle payment disputes between payers and providers when they can't resolve them on their own.
But the exact details didn't emerge until September, and when they did, they caused an uproar.
That's because organizations like the American Hospital Association and the American Medical Association, as well as lawmakers, say that the regulation issued Sept. 30 directs arbitrators "to lean toward picking the amount closest to the median in-network rate negotiated for the type of care involved," Kaiser Health News reported, which they say unfairly favors insurance companies.
In fact, the AHA and AMA are among several groups who have filed lawsuits to change that provision.
Another key element of the rule is delayed: HHS said it would defer the good faith estimate requirement for insured patients "until rulemaking to fully implement this requirement…is adopted and applicable."
Meanwhile, another major surprise billing issue is on the agenda for the new year: After ground ambulance bills were left out of the No Surprises Act, a new federal advisory committee will provide recommendations about how consumers can be protected against "exorbitant charges and balance billing when using ground ambulance services."
3. A renewed focus on the workforce
As the world enters the third year of the COVID-19 pandemic, the workforce has seen dramatic changes, and the revenue cycle is not immune. Nearly two years into the pandemic, many revenue cycles continue to work remotely, and leaders have developed strategies to manage a workforce that isn't physically together.
Those have included replicating the office infrastructure at home with all the equipment and technology employees need; requiring employees—and managers—turn on their cameras and microphones to stay active and engaged in virtual meetings; and doubling down on communications, including formalizing tiered huddles, holding town hall meetings, and having regular leadership-level check-ins.
A focus on the workforce also means focusing on the future. As baby boomers begin to retire and the revenue cycle increasingly requires more specialized skills, it's crucial for revenue cycle leaders to think seriously about succession planning, said Cassi Birnbaum, PeaceHealth's senior enterprise director of HIM, coding, and CDI.
Finally, revenue cycle leaders have started to think outside traditional roles and staff payment structures to ensure success. For example, at UC San Diego Health customer service is the highest paid position in the revenue cycle, and University of Wisconsin Health hired a denials management nurse to help the revenue cycle recognize trends, gain better insight into the tactics payers use to deny claims, and successfully appeal claims.