The recent UAW strike draws on similar workforce concerns revenue cycle leaders have been facing with their staff for years: technology advancement.
While the recent United Auto Workers’ (UAW) strike is historic for many reasons, the union’s asks aren’t a far cry from the demands of the healthcare workforce.
One demand by the UAW, though, parallels an issue revenue cycle leaders have been facing with their workforce for years: wanting to know where they stand in the wake of technology advancement.
For context, the UAW is voicing its concern—along with better employment benefits and wage increases—over job security related to an increase in electric-powered vehicles that require fewer parts and fewer laborers. They want to make sure their jobs remain secure as technology advances. Who else is thinking the same? Your revenue cycle staff.
We know that healthcare organizations are embracing revenue cycle automation and AI at a fast pace, with executives seeing technology as a means of improving the quality and accuracy of tasks, reducing manual labor, and improving clinical and staff workflows.
In fact, automation in the revenue cycle isn’t an if, it’s a when, and each time you implement new technology in the department, it’s not improbable that your revenue cycle staff is questioning their viability.
While the concerns of your revenue cycle staff might differ slightly from the situation faced by the UAW, at a time when workforce retention is top of mind and nearly half of healthcare workers fear that AI could take their jobs, hospital leaders need to pay attention to these massive industry strikes.
Luckily, there are a few valuable lessons that hospital leaders can draw from in this labor dispute to protect their teams from the fears of job insecurity as automation and AI continues to take hold of the revenue cycle.
Create open and transparent communication
Leaders need to maintain open lines of communication with revenue cycle staff and address concerns about technology and AI encroaching in on their department. Be transparent about the organization's plans and reassure staff that technology is meant to complement their work, not replace it.
Invest in staff training
Demonstrate your commitment to employee growth by investing in continuous training and upskilling. Show that the organization values its employees' development and is willing to adapt to changing technology together.
In fact, advancing employees’ skills should be viewed through the lens of your business objectives. As upskilling and reskilling are increasingly part of the workplace conversation, business leaders need to approach these programs as far more than short-term soultions for staff.
Emphasize job security
Make it clear that while technology may change job roles, it doesn't necessarily mean a loss of jobs. Emphasize the importance of human judgment, empathy, and critical thinking the revenue cycle—skills that are not easily replaceable by AI.
On the front and back end, patients value the human touch in these interactions, and this will continue to be a critical aspect of the revenue cycle.
And as for critical thinking, coders or clinical documentation improvement staff often use these skills to query providers and report more accurately—something AI can’t do.
Make it known AI is a tool, not a replacement
Revenue cycle leaders implement AI and technology to enhance the efficiency and accuracy of revenue cycle processes, not to necessarily replace FTEs—so make sure your staff knows that is the intention. Showcase how these technologies can reduce administrative burdens, allowing them to focus on more strategic and patient-centered tasks.
Employ collective problem-solving
Engage staff in discussions about how technology can improve their workflow and address pain points. Encourage them to provide input and be part of the decision-making process when adopting new technologies.
Provide fair compensation and benefits
While there’s a fine line between competitive salaries and financial stability, leaders should ensure that revenue cycle staff receive competitive compensation and benefits. Address any disparities or concerns related to wages and benefits promptly.
Share the long-term vision
Share the organization's long-term vision for revenue cycle technology and how staff will be integral to achieving it. Make it clear that their roles will evolve and adapt alongside technology. Leaders also need to remember that revenue cycle technology is only as good as the human staff that runs it behind the scenes.
That all being said, incorporating these strategies can help revenue cycle leaders proactively address concerns among their staff. Leaders need to ensure a more stable and collaborative work environment, which will reduce the likelihood of future workforce issues due to automation and AI advancements.
In the largest price transparency fine yet, University of Florida Health North was docked $979,000 by CMS.
UF Health North received a $979,000 price transparency fine due to several compliance violations under the No Surprises Act—a big reminder that revenue cycle leaders need to be prioritizing compliance.
According to CMS, UF Health North failed to uphold several requirements under the price transparency requirement:
Failure to update standard charge information annually: Hospitals are required to update the standard charge information annually. UF Health North failed to do so, leading to noncompliance.
Incomplete data elements in the list of standard charges: Hospitals must include all corresponding data elements in the list of standard charges, including descriptions for each item and service, payer-specific negotiated rates, and de-identified minimum negotiated charges. UF Health North did not fully adhere to these requirements, CMS says.
As the number of fined organizations is sure to grow, revenue cycle leaders need to make sure to streamline price transparency strategies.
Here are a few tasks that revenue cycle leaders need to make sure are prioritized:
Regularly update pricing information: Revenue cycle leaders should establish processes to ensure that standard charge information is updated by revenue cycle teams at least once annually, as mandated by CMS. This involves keeping track of changes in charges for services and items.
Comprehensive data inclusion: This is an area UF Health received the most dings, so leaders need to meticulous in making sure all relevant data elements in your list of standard charges is present. This includes descriptions, payer-specific negotiated rates, and deidentified minimum negotiated charges.
Implement or streamline shoppable services display: Organizations need to have a user-friendly online display of shoppable services, making it easy for patients to access and understand pricing information for common procedures.
Conduct regular compliance audits: Hospitals should conduct routine self-audits to assess their compliance with price transparency regulations. Really, audits should be in place for all compliance regulations. Also, make sure to identify and rectify any deficiencies promptly.
Educate staff: Your entire revenue cycle staff—from front end to backend—should be well-informed about the importance of price transparency compliance and trained to provide patients with accurate cost information.
Engage legal and compliance experts: The revenue cycle isn’t siloed. Continually seek the advice of the legal and compliance experts in your organization (or even outside your organization if necessary).
Stay informed: Revenue cycle leaders should be staying up-to-date with evolving regulations related to price transparency. Regulations in general are everchanging, so staying abreast of even the most mundane regulations can save you big in the long run.
Respond promptly to CMS notices: If your organization receives a notice of noncompliance from CMS, it is crucial to respond promptly and take corrective actions as required.
As denial prevention and accurate reimbursement weigh heavy on revenue cycle leaders, staying up to date on code updates minimizes these challenges greatly.
Having teams report incorrect or outdated codes can result in claim denials, delays in reimbursement, and revenue disruptions.
While coding seems like merely a middle revenue cycle task, accurate reporting also impacts financial reporting and analysis as it affects resource allocation, budgeting, and strategic planning. In this sense, incorrect reporting could potentially skew financial reports and hinder effective decision-making.
This makes knowledge of coding changes essential for everyone from the biller to the revenue cycle leader.
The most recent coding update comes from the American Medical Association (AMA) as it recently released the 2024 CPT® code set, which includes hundreds of new codes and a push for more inclusivity for certain patients.
Here are five key takeaways from the AMA’s 2024 CPT code update that revenue cycle leaders need to know.
The AMA is taking steps to improve accessibility for Spanish-speaking patients: The AMA is incorporating Spanish language descriptors for over 11,000 medical procedures and services in the 2024 CPT code set.
There are over 300 updates to the code set: The 2024 update includes 230 additions, 49 deletions, and 70 revisions.
COVID-19 immunization reporting has been streamlined: The AMA consolidated more than 50 codes related to COVID-19 immunization reporting. The consolidation of these codes and the introduction of provisional codes for specific vaccine products demonstrate are a push toward more accurate and streamlined reporting for the virus.
RSV immunization codes have been added: For organizations treating patients of all age groups, but especially children and the elderly, there are new CPT codes for reporting product-specific RSV immunizations. Accurate coding for these immunizations can aid in data-driven planning and allocation of resources as these immunizations are fairly new.
Clarifications in E/M services reporting were made: Revenue cycle leaders should be aware of the revisions made to the reporting of evaluation and management (E/M) services. These revisions aim to provide clarity and consistency in coding, including changes related to office visits, split/shared E/M visits, and hospital inpatient services.
As previously reported, there are also hundreds of changes to the diagnosis code set being implemented October 1.
Vertical relationships between physicians and health systems are increasing in the U.S. What does that mean for finance leaders?
Market disruptors are seemly everywhere for healthcare executives, and vertical integration is one of them. While CFOs know that it’s best to partner when and if you can, a new study is showing that the physician/health system “vertical relationship” may have a negative financial impact on an organization, so it’s best to plan accordingly.
A study recently published in JAMA Health Forum examined the influence of the vertical relationship between primary care physicians (PCP) and large health systems, and it has shed light on critical aspects of healthcare utilization, referral patterns, spending, and readmissions.
The study reviewed over 4 million observations of commercially insured patients in Massachusetts treated by physicians newly aligned with a health system either through ownership, joint contracting, or affiliation and compared outcomes with physicians who did not have a vertical relationship.
Vertical relationships between PCPs and large health systems were associated with a significant increase in specialist visits per patient-year, the study said. This directly impacts the utilization of specialist services and could potentially lead to higher costs associated with specialist care.
The study also demonstrated a rise in total medical expenditures per patient-year in cases where PCPs had vertical relationships with large health systems, and the increased spending on patient care could affect the financial health of your organization.
The JAMA study also found an increase in the number of emergency department visits and hospitalizations within the health system when PCPs had vertical relationships. This could place additional strain on hospital resources and require more substantial financial allocations for emergency and inpatient care.
Importantly though, the study did not identify any differences in readmission rates.
How can CFOs prepare?
Another recent study showed an uptick in physicians integrating with larger organizations with the primary driver being the need to negotiate higher payment rates with payers. Since vertical integrations and poor payer rates are seemingly here to stay, it can be in an organization’s best interest to adapt to the new financial landscape.
Here are a few ways finance leaders can prepare for physician integrations:
Understand the financial implications of these relationships: The study suggests that vertical relationships between PCPs and large health systems lead to increased healthcare spending. CFOs must be vigilant in monitoring and managing these financial aspects to ensure the hospital remains financially sustainable.
Be prepared for resource allocation: The rise in emergency department visits and hospitalizations within the health system may necessitate resource allocation adjustments. CFOs need to assess the impact on staffing, equipment, and facility requirements to accommodate increased utilization.
Take a look at the larger revenue considerations: Leaders should evaluate how these vertical relationships influence hospital revenue. An influx of patients into the health system can be beneficial if it leads to higher revenue, but it must be balanced against increased spending on patient care.
Don’t forget your payer negotiations: The strained payer/provider relationship may never ease up, so it’s beneficial for leader to understand how the impact of vertical relationships can inform negotiations with payers. CFOs and revenue cycle leaders can use this knowledge to negotiate contracts and reimbursement rates that align with the changing dynamics.
The Lompoc Valley Medical Center (LVMC) is out $5 million from a recent false claims settlement—and there are several critical takeaways for revenue cycle leaders.
Healthcare leaders continue to fight against poor operating margins, reduced reimbursement, and inflated expenses, and at a time when budgets are tight, revenue cycle leaders are under more pressure than ever to streamline processes and ensure financial stability.
The recent settlement involving LVMC in California, where the hospital agreed to pay $5 million to resolve allegations of false claims violations, provides several critical takeaways for revenue cycle leaders that can’t be overlooked as organizations are already financially strained.
What happened?
LVMC was accused of violating the False Claims Act and the California False Claims Act via a whistleblower. The allegations revolve around the submission of false claims to California's Medicaid program, Medi-Cal.
The critical components of this settlement involve LVMC's alleged involvement in submitting false claims for enhanced services provided to Medi-Cal members between January 1, 2014, and June 30, 2016.
These services were not considered allowed medical expenses as per the contract between California's Department of Health Care Services and CenCal Health, the county-organized health system responsible for arranging healthcare services for Medi-Cal patients.
Additionally, it was claimed that the payments received by LVMC did not reflect the fair market value of the enhanced services or were duplicative of services already required by LVMC. The payments were also alleged to constitute unlawful gifts of public funds, violating the California Constitution.
In the end, LVMC agreed to pay $5 million to resolve the allegations.
How can you ensure it doesn’t happen to you?
Revenue cycle leaders play a pivotal role in ensuring the financial health and compliance of their organizations, and the LVMC settlement is proof noncompliance carries significant implications for an organization.
Luckily there are several takeaways revenue cycle leaders can implement to avoid the same outcome:
Financial impact: The $5 million settlement paid by LVMC underscores the financial consequences of non-compliance with healthcare regulations. Revenue cycle leaders need to be aware that these violations can result in substantial monetary penalties, potentially jeopardizing an organization’s financial stability.
False Claims Act: Understanding the False Claims Act is essential for revenue cycle leaders and their teams as violations can lead to severe penalties. It emphasizes the need for meticulous billing practices and adherence to regulatory guidelines.
Medi-Cal and Medicaid: As we know, each payer is different, so revenue cycle teams must be well-versed in the rules governing each individual payer (and in this case Medicaid) to ensure proper billing and compliance.
Contractual agreements: The allegations in the settlement highlight the importance of hospitals adhering to contractual agreements with government agencies and payers. Leaders need to oversee (or have a team that oversees) compliance with these agreements to avoid potential legal issues.
Market valuation of services: Leaders need to assess the fair market value of services provided by their institutions. Overcharging or providing services that are not considered allowed medical expenses can lead to legal and financial repercussions.
Gifts of public funds: Understanding the legal boundaries related to the use of public funds is crucial for organizations. If not someone from the revenue cycle, then an organization’s legal team must ensure that financial transactions involving government funds comply with relevant laws and regulations.
Whistleblower provisions: The involvement of a whistleblower in this case serves as a reminder that employees within healthcare institutions may report alleged violations. Revenue cycle leaders should implement robust internal compliance programs to detect and address potential issues before they escalate.
As mentioned, this settlement serves as a significant reminder of the legal and financial risks associated with non-compliance.
By bolstering compliance protocols, reviewing contractual agreements, assessing market valuations, and investing in education and technology, revenue cycle leaders can not only avoid legal pitfalls but also help to enhance the overall financial health of their organization.
In an effort to soften the payer/provider relationship, many large health insurers are rolling back on prior authorizations.
UnitedHealthcare (UHC) is the latest to cut back on its prior authorization list.
Beginning last week, the health insurer removed hundreds of codes from its prior authorization list—mostly for genetic testing. More codes for radiology services are scheduled to be removed November 1.
Prior authorizations have long been a pain point for revenue cycle leaders, so while UHC says these removed codes account for tens of thousands of prior authorization requests a year, how much will it really help your operations?
Between the administrative time spent on submitting requests to the heap of denials they can accrue, any reduction in volume will likely speed up some revenue cycle processes—but as UHC is one payer in a large market, without a complete overhaul, this change is unlikely to make a huge dent in the overall revenue cycle prior authorization burden.
As leaders will likely still struggle with the administrative burden in 2024 and beyond, automation may be the key to lighten the workload. In fact, 39% of respondents in a recent survey said the biggest area of focus for their revenue cycle management automation in 2024 will be on prior authorization.
The decision for UHC to roll back prior authorizations comes on the heels of a substantial back-and-forth with gastrointestinal providers earlier this year.
UHC was set to require added prior authorizations for nearly half (47%) of gastrointestinal endoscopies starting June 1, saying more prior authorizations were needed to curb costs related to alleged overuse of some of these procedures by physicians.
But, after intense pushback from large medical associations, UHC pulled back.
The District Court for the Eastern District of Texas’ ruling on striking down several regulatory provisions related to the qualified payment amount (QPA) calculation is yet another win for providers.
As we know, this is the third time the court ruled to set aside certain regulations pertaining to the No Surprises Act, but this ruling specifically aimed at QPA calculations will help ensure providers have a fair fight with payers.
This is important because the design of the QPA is critical to the No Surprises Act’s mission to promote lower premiums and costs, both for consumers directly for out-of-network services as well as through the arbitration process.
QPA calculations have long been said to empower insurers to significantly reduce their in-network rates or terminate in-network agreements altogether. This can artificially lower QPAs and does not reflect market rates for services. Further, payers have been accused of miscalculating the QPA, which drives payments down even lower.
In fact, providers have argued that the QPA methodology and the miscalculations have led to QPAs that “don’t even pass the laugh test” as they are so low that they are even significantly below Medicare and Medicaid payment rates.
Having a just QPA will allow providers a fair fight in the already-burdensome independent dispute resolution process.
Did you miss the news?
Last week, a Texas judge ruled to vacate several regulations relating to the No Surprises Act that set up payment dispute resolutions between certain out-of-network providers and payers, specifically, the QPA calculations.
The court specifically disallowed several regulatory provisions related to the QPA calculation, including those that could enable insurers to include in the calculation of QPAs contracted rates for services that providers have not provided, as well as allowing self-insured group health plans to use rates from all plans administered by a third-party administrator in calculating the QPA. The No Surprises Act arbitration process is currently on hold as a result of separate litigation challenging other aspects of the regulations.
When it comes to improving patient billing and payment processes, there's a bright future for vendor consolidation.
For years now, the revenue cycle has been seeing a boom in automation and technology, giving patients better access to patient portals, digital front doors, and payment options.
In fact, revenue cycle leaders are constantly in search of ways to better secure revenue by bolstering their technology and streamlining processes—especially when it comes to patient billing and payments.
While patients may be getting an information overload through their bills and statements, once this information is paired down and streamlined, the advancement of technology can make the patient financial experience easier and more transparent.
But at a time when technology in the billing and payment space is king and almost all executives that plan to purchase rev cycle technology are willing to consider "bolt-on" vendors, can there be too much of a good thing? Some leaders say yes—especially since every individual tech solution needs to be meticulously monitored and maintained.
The ultimate goal is to give the patient the ability to make payments and to interact with an organization on financial issues in any manner that they see fit, but is throwing new tech in at every step really the right decision?
Better yet, does your revenue cycle staff even have the bandwidth, or cash, to manage multiple vendors in one space?
Tonie Bayman, director of revenue recovery at Memorial Hermann Healthcare System, says that this is why the industry will likely see more vendor consolidation in the next five years as providers invest even more on all-encompassing options for improving patient payment processes.
“[Revenue cycle leaders] have a lot to manage now, and it’s better for them if they can pair down to one or two vendors,” she says. “There’s going to be more consolidation and newer technology that’s going to help manage some of this complexity,” says Bayman.
Joann Ferguson, vice president of revenue cycle at Henry Ford Health, told HealthLeaders that her advice to other health systems considering investing in technology is to do their due diligence and find the right fit for your organization—which for some, might not be yet another bolt-on option.
"Going for the quick fix or using last year’s technology because it's cheaper will only make change more painful in the future," Ferguson said. "That means finding a partner who understands rev cycle operations and AI, and what your team needs to be successful.”
Revenue cycle leaders need to keep up with ever-evolving technology while keeping staff workloads streamlined and budgets tight.
So, while technology is a necessity in the revenue cycle, it’s never been a set it and forget it option. Having a mixed-bag of bolt-on vendors in back end may seem like the right decision, but the complexity of vendor management may not be worth it for some—especially as the industry trends toward larger, all-encompassing options.
Is it possible to make technology management less complex while still improving the patient experience? Leaders are hopeful.
No recent regulation has thrown revenue cycle processes for a loop like the No Surprises Act.
CMS’ price transparency requirements, found within the No Surprises Act, have been implemented for years now, and it’s clear that not many recent regulations have caused such a shakeup in revenue cycle processes.
From streamlining technology to training staff, many revenue cycle leaders had to scramble to adhere to the law and remain out of CMS’ crosshairs.
In fact, PatientRightsAdvocate.org recently awarded 15 hospitals and health systems for what it says is exemplary transparency compliance, including in some cases a record of significant improvement, which the group says demonstrates a commitment to putting patients over profits.
Awarded by the group were the following hospitals and health systems:
Hospitals
Best-in-Class: Rush University Medical Center – Chicago, IL
Baton Rouge General - Mid City – Baton Rouge, LA
Grandview Medical Center – Birmingham, AL
Mercy Hospital Downtown Bakersfield – Bakersfield, CA
MetroHealth Medical Center – Cleveland, OH
Pullman Regional Hospital – Pullman, WA
Ridgeview Medical Center – Waconia, MN
Robert Wood Johnson University Hospital New Brunswick – New Brunswick, NJ
Saint Tammany Parish Hospital – Covington, LA
UW Health University Hospital – Madison, WI
Hospital Systems
Kaiser Permanente – Oakland, CA (98% compliance)
Community Health Systems – Franklin, TN (97% compliance)
Universal Health Services – King of Prussia, PA (92% compliance)
CommonSpirit Health – Chicago, IL (88% compliance)
LifePoint Health – Brentwood, TN (83% compliance)
For those hospitals and health systems that are still working to streamline compliance, there are lessons to be learned from those systems that are coming out ahead.
For example, Tina Barsallo, vice president of revenue cycle operations at Lifepoint Health, spoke to HealthLeaders about the health systems’ strategies in compliance.
To really get ahead of the game, Barsallo said Lifepoint created an internal pricing transparency team in the year prior to the regulation’s effective date.
Team members spanned across the entire organization and included revenue cycle operations, revenue cycle analytics, compliance, managed care, legal, and project management. Barsallo says she even brought in other team members as needed, such as the facility revenue cycle management leaders and CFOs.
Its pricing transparency team evaluated the requirements thoroughly and outlined the proper path for Lifepoint, and then executed on each aspect to ensure the requirements were met. Barsallo says the team continues to meet regularly to confirm there have been no changes to the requirements, and the revenue cycle team handles on-going monitoring of the websites and links, as well as the annual refresh.
Even if you’re already behind on compliance, it’s not too late to make a change. Barsallo suggests that revenue cycle leaders pull a team together to create joint ownership and partnership in creation of any price transparency tools and to help drive consistency and compliance.
“Reach out to peers to brainstorm on ways they have accomplished compliance, so you don’t need to reinvent the wheel. It is extremely helpful to collaborate with other providers and health systems,” Barsallo says.
CFOs are considering expanding their outpatient footprint to ward off incessant inflation and inadequate payment rates.
CMS recently released its fiscal year (FY) 2024 inpatient prospective payment system (IPPS) final rule increasing payment rates by a net 3.1%. Overall, this will increase hospital payments by $2.2 billion compared to FY 2023.
The AHA, unsurprisingly, was quick to strike back at the “woefully inadequate” payment rate increase for FY 2024.
In a statement shared with the media, Ashley Thompson, AHA’s senior vice president for public policy analysis and development, said, “The AHA is deeply concerned with CMS’ woefully inadequate inpatient and long-term care hospital payment updates. The agency continues to finalize rate increases that are not commensurate with the near decades-high inflation and increased costs for labor, equipment, drugs and supplies that hospitals across the country are experiencing.”
While a $2.2 billion increase seems significant, hospitals are facing historic financial challenges, meaning CFOs are digging deep to find ways to ensure financial stability.
Most hospitals underperformed in June of this year, even as the median year-to-date operating margin index increased to 1.4%, compared to 0.7% in May.
These challenges highlight the fact that leaders can’t depend on payment rate increases to keep them afloat.
"This 'new normal' is an incredibly challenging environment for hospitals," Erik Swanson, senior vice president of Data and Analytics with Kaufman Hall, said in a press release regarding its market analysis.
"It's time for hospital and health system leaders to begin developing and implementing a strategy for long-term sustainability, including expanding their outpatient footprint and re-evaluating where finite resources are being utilized," Swanson said.
And some CFOs have been planning just that.
The key to warding off challenges caused by rising inflation and poor reimbursement rates is reassessing any plans for growth and major capital, Matthew Arsenault, CFO at Baptist Health South Florida, recently toldHealthLeaders.
“We are in a community and a service area that is growing through people continuously moving into South Florida. So, we want to make sure that we provide care, but deciding which projects happen when and evaluating the cost of those projects and inflationary environment is something that we're constantly doing more of now, and more frequently than we have been historically because of the current inflationary environment,” he said.
When planning growth and investments in order to maintain financial stability, Arsenault said the system looks toward expanding outpatient footprints.
“We've always had a very large outpatient footprint throughout the community, and I think that really served us and our patients well. It's all about how you provide easy access to care for patients, whether it be in a virtual setting, whether it be in an outpatient clinic, or whether it be in an urgent care center,” he said.
Growing and increasing revenue is about continuing to build upon that footprint, Arsenault said. “I think that shift to outpatient is a big part of [financial stability].”
