HealthLeaders' new series highlights five essential governing updates that cover every aspect of the revenue cycle that leaders need to know. Check back in each month for more regulatory updates.
The revenue cycle is complex, detailed, and always changing, so staying on top of regulatory updates and latest best practices requires revenue cycle leaders' constant attention in this ever-changing industry. In this revenue cycle regulatory roundup, there were an ample number of updates published by CMS and the OIG in April, including the release of the fiscal year 2023 IPPS proposed rule.
Here are the five updates you need to know.
1. There's no sign of healthcare spending slowing down as Medicare spending is projected to exceed $1 trillion in 2023.
According to CMS, although considerable uncertainty remains, the COVID-19 public health emergency (PHE) is expected to continue to influence the near-term outlook for national health spending and enrollment.
The report showed that near-term expected trends in health spending and insurance enrollments are significantly influenced by the COVID-19 PHE. It found that while there was an increased demand for patient care in 2021, the growth in national health spending slowed from 9.7% in 2020 down to 4.2% in 2021, likely as supplemental funding for public health activity and federal programs related to the COVID-19 pandemic kicked in.
The report also showed that Medicare spending growth is projected to average 7.2% between 2021 and 2030, the fastest rate of all major payers. Medicare spending is projected to exceed $1 trillion for the first time in 2023.
2. Tighten up your revenue cycle to avoid major penalties as the Office of Inspector General (OIG) takes aim at fraud.
The OIG published an updated list of fraud self-disclosures that took aim at multiple organizations.
For example, Advanced Dermatology & Skin Cancer Center (ADSCC) of Ohio, reached a $50,000 settlement agreement with the OIG to resolve allegations that offered and provided remuneration to a dermatology practice in the form of a printer cartridge, payment for holiday party expenses, and payment to a dermatology employee to prepare, pack, and complete related paperwork for specimens to be delivered to ADSCC.
Also, AltheaDX, of California, reached a settlement agreement of more than $72,000 with the OIG to resolve allegations that it violated civil monetary penalties law by submitting claims for payment for pharmacogenic tests that were not ordered by a physician.
The National Medical Services II, of Florida, reached a settlement agreement of more than $930,000 with the OIG to resolve claims that its mid-level providers fraudulently recorded personally performed services as if the services were performed by an employed physician, then improperly submitted claims for those services.
The list also included settlements to resolve allegations of violating civil monetary penalties law by employing individuals an organization knew or should have known were excluded from participation in federal healthcare programs. Those entities include River Hospital of New York, Heritage Health of Danville of Illinois, and Harney County Health District of Oregon.
3. Organizations can breathe a sigh of relief as COVID-19 PHE was renewed.
CMS continues to gradually end some emergency blanket waivers allowed under the COVID-19 PHE for some providers, but for now the 1,135 waivers remain intact for acute care and critical access hospitals.
A notice was published announcing that the COVID-19 PHE has been extended effective April 16, 2022. This will extend the PHE and all applicable waivers tied to it for an additional 90 days.
4. CMS released the FY 2023 IPPS proposed rule and organizations are not happy.
CMS released the fiscal year (FY) 2023 IPPS proposed rule with proposals for the annual ICD-10 code update, new programs for quality reporting, and increases to hospital payment rates. Providers were not happy.
CMS projects an increase in operating payment rates by 3.2% based on a projected hospital market basket update of 3.1% reduced by a 0.4% productivity adjustment and increased by a 0.5% statutory adjustment.
"We are extremely concerned with CMS' proposed payment update of only 3.2%, given the extraordinary inflationary environment and continued labor and supply cost pressures hospitals and health systems face," Stacey Hughes, executive vice president of the American Hospital Association, said in a statement. "Even worse, hospitals would actually see a net decrease in payments from 2022 to 2023 under this proposal because of proposed cuts to disproportionate share hospital (DSH) and other payments."
Hughes continued by calling the decision "unacceptable" given that hospitals and health systems are still dealing with the COVID-19 pandemic and the variety of challenges the crisis has placed on their ability to provide patients with essential services.
5. Be on high alert: OIG announced a nationwide crackdown on healthcare-related COVID-19 fraud.
The OIG—in conjunction with the Department of Justice—published a notice announcing nationwide coordinated law enforcement actions to combat healthcare-related COVID-19 fraud. The action resulted in charges against 21 defendants across nine federal districts and resulted in over $149 million in false billings. Schemes involved fraudulent COVID-19 testing, billing for sham telemedicine encounters, misappropriation of Provider Relief Fund monies, and more.
Amanda Norris is the Revenue Cycle Editor for HealthLeaders.