Since revenue integrity departments tend to be relatively new, many leaders wonder how to best elevate a revenue integrity program.
As the revenue cycle continues to be an area of focus for organizations looking to prosper in 2023, revenue cycle leaders have turned to streamlining (and even creating) revenue integrity departments to reduce the risk of noncompliance, optimize payment, and minimize the expense of fixing problems downstream with claim edits.
But, where should revenue cycle leaders start?
“The question is more urgent than ever, but changes in the industry due to budget constraints, available skill sets, reactive cultures, and the inability to measure performance—or even define what to measure—make answers harder to come by. At the end of the day, it comes down to: How do I do more with less and do so effectively?” Caroline Znaniec, managing director of healthcare business performance improvement with Protiviti Inc., told the NAHRI Journal.
Znaniec says two important items to focus on when looking to optimize a revenue integrity department are objectives and strategies.
Here’s what Znaniec had to say:
Objectives
Better-performing revenue integrity programs have clear objectives with defined roles and expectations. This prevents overlap between functions, including those of the billing office, compliance, internal audit, and clinical operations. Your revenue integrity program charter should include a clear objective.
Strategies
In addition to stating the objectives of the revenue integrity program, specific key strategies can help a program maintain focus to meet its objectives. Better-performing organizations employ these strategies in creating, implementing, and sustaining their revenue integrity programs.
When combined, these strategies create a culture of revenue integrity within a provider organization, which is vital to sustaining the program and its efforts.
The strategies are as follows:
Create staff awareness at all levels on the individual and provider organization’s responsibilities through inclusion of responsibilities in job descriptions, on-boarding activities, and annual education
Provide periodic reviews across the organization in a well-defined, documented, and thorough manner through the creation and implementation of an annual work plan
Design and implement a monitoring program for identified high-risk areas; this program should include the development of review tools, analysis of results to identify root causes and develop corrective action plans, tracking of action plan implementation, and verification of improvement
Create and maintain a revenue integrity committee (or similar initiative) to ensure the program is meeting its primary objectives
Communicate findings of the revenue integrity monitoring activities to executive management
Claims denials are increasing between 10%-15% according to a recently released survey.
According to a recently released survey conducted by Experian Health, the top three reasons for an increase in claims denials were insufficient data analytics (62%), lack of automation in claims/denials process (61%), and lack of thorough training (46%).
These results came from surveying 200 healthcare professionals, primarily in executive or management positions, who actively take part in the decision-making processes for their organizations' claims management systems.
Additionally, nearly three out of four respondents reported that reducing denials is their highest priority, and 70% said that it is more important than prior to the pandemic.
The reasons indicated for this higher priority include payer policy changes occurring more frequently (67%), reimbursement taking longer (51%), errors on claim submissions increasing (43%), and denials increasing (42%). Those who reported denials increasing pointed to operational challenges such as insufficient data and analytics to identify submission issues, lack of automation in claim submission/denials prevention process, lack of staff training, and lack of in-house expertise, among others.
“[The increase in denials] represents billions of dollars that will take longer than anticipated to be reimbursed—if reimbursed at all—which puts pressure on providers’ cash flow,” the study authors wrote. “The overhead to rework and resubmit these claims can be considerable and further dilute reimbursement totals.”
Almost all respondents indicated they had technology in place to help improve claims and reduce denials, with more than half (52%) having updated or replaced their existing claims process technology, 45% saying they automated tracking of payer policy changes. Providers also invested in patient portals (44%), accurate estimates (40%), and digitizing the registration process (39%).
HealthLeaders' regulatory round up 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 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 December, including insights on telehealth use and the OIG's semiannual report to Congress.
Here are the five updates you need to know.
There was a dramatic increase in telehealth use during the first year of the pandemic.
The OIG published a report in conjunction with the Department of Defense, Office of Personnel Management, Department of Veterans’ Affairs, Department of Labor, and Department of Justice, to examine telehealth across select health care programs within those agencies and potential program integrity risks during the first year of the COVID-19 pandemic.
The report showed an unsurprisingly dramatic increase in telehealth use during the first year of the pandemic, as approximately 37 million individuals–13 times the number of individuals from the previous year–across healthcare programs in those six agencies used telehealth during the first year of the pandemic.
The percentage of individuals using telehealth varied by program, as the VA had the most telehealth usage (87%), followed by Tricare (49%) then Medicare (43%). The Department of Justice prisoner health care services saw the lowest rate of telehealth usage (2%).
The report also looked at ways the agencies made telehealth available during the pandemic, how the coverage compared across agencies, and potential program integrity risks across programs. It identified potential risks–such as upcoding, duplicate claims, high-volume billing, unnecessary durable medical equipment, or laboratory tests associated with telehealth visits–which will likely be future areas of focus for the OIG.
The OIG's Fall 2022 Semiannual Report to Congress was published.
Also in December, the OIG published its Fall 2022 Semiannual Report to Congress, which reviews OIG work from April 1 to September 30, 2022. The OIG detailed its monetary totals for expected recoveries and highlighted its most significant audit findings from this period.
Labs with questionably high billing for additional tests alongside COVID-19 tests warrant further scrutiny the OIG said.
The OIG also published a review of certain diagnostic testing along with COVID-19 tests. These add-on tests included individual respiratory tests (IRT), respiratory pathogen panels (RPP), genetic tests, and allergy tests. The OIG noted that while it is not unusual for labs to bill for multiple types of tests on the same claim, it is concerned about certain patterns of billing involving this type of testing.
The OIG examined all Part B claims paid for COVID-19 tests during 2020 with these four add-on tests. It found that 378 labs billed Part B for add-on tests at questionably high levels compared to the 19,199 other labs whose claims were examined.
OIG concerns included high-volumes of add-on tests on claims for COVID-19 tests, high payment amounts from including add-on tests, and labs who billed for add-on tests in combination with COVID-19 tests with little variation among patients, suggesting the add-on tests may not have been specific to an individuals’ needs. Payment amounts for claims which included these tests were significantly higher than claims with just COVID-19 tests. The OIG referred the labs in question to CMS for further review.
A proposed rule on advancing interoperability and improving prior authorization processes was published.
CMS published a proposed rule regarding improving interoperability and reducing challenges related to prior authorization. This rule replaces a proposed rule from December 2020 titled “CMS Interoperability and Prior Authorization (85 FR 82586),” and it builds on a final rule published in May 2020 titled “CMS Interoperability and Patient Access (85 FR 25510).” This proposed rule also incorporates feedback CMS received from the December 2020 proposed rule.
The rule is geared overall toward Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid and CHIP managed care plans/entities, and Qualified Health Plan issuers on the federal exchanges, as it aims to improve electronic exchange of health care data through various APIs.
It also includes proposals to require payers and Medicare Advantage organizations to implement electronic prior authorization and send decisions within 72 hours for expedited requests and seven days for non-urgent requests. It would add a new electronic prior authorization measure for certain hospitals and CAHs participating under the Medicare Promoting Interoperability Program and in MIPS.
The rule also includes five requests for information on the following topics:
Accelerating the Adoption of Standards Related to Social Risk Factor Data
Electronic Exchange of Behavioral Health Information
Improving the Electronic Exchange of Information in Medicare Fee-for-Service
Advancing the Trusted Exchange Framework and Common Agreement
Advancing Interoperability and Improving Prior Authorization Processes for Maternal Health
CMS published a press release and fact sheet on the rule on the same date. Comments are due by March 13, 2023.
National healthcare spending grew in 2021.
CMS published a press release regarding the 2021 National Health Expenditures (NHE) Report, which found that US healthcare spending increased in 2021 by 2.7% to reach a total of $4.3 trillion in total national healthcare spending.
This was a far slower increase than the 10.3% jump in 2020, and CMS attributed the slower growth to the decline in government expenditures for health care that followed strong growth in 2020 due to the COVID-19 pandemic response. The share of the GDP devoted to health decreased from 19.7% in 2020 to 18.3% in 2021, but that is still higher than the 17.6% share from 2019. Medicare spending increased by 8.4% in 2021, a significant jump from a 3.5% increase in 2020.
Revenue cycle leaders say helping patients navigate the billing process is essential in creating a positive patient financial experience.
How patients are billed plays a large role in the overall patient financial experience and satisfaction. Because of this, revenue cycle leaders said that helping patients navigate the billing process is essential in creating a positive patient financial experience, especially considering the No Surprises Act.
Paper statements work, but the digital age has pushed organizations into not only wanting to add in that digital billing experience, but they are needing to. Patients are now expecting both digital and automated options when it comes time to pay their bill.
When first taking that step toward a digital billing experience, patient education is once again vital to success. Organizations can offer the most sophisticated bill-pay technology, but what use is technology if a patient doesn’t know how to use it?
Three prominent revenue cycle leaders addressed this conundrum during our recent revenue cycle roundtable in Nashville, TN. They discussed why it’s imperative to improve the patient billing experience and examined the benefits of patient education in light of the No Surprises Act.
Read on to learn what they had to say.
Savanah Arceneaux, Director of Patient Financial Services, Ochsner Health: “In terms of the legislation that's being implemented with pricing transparency and surprise billing, it's important to get the patients involved in their patient financial journey. Ensuring that they understand what they're seeing when they get a bill and knowing what questions to ask is important. And even helping them anticipate what that bill might look like before they get it allows them to understand their benefits ahead of time.
At Ochsner we proactively provide estimates to our patients prior to being seen and this helps them understand the differences between the charges, contractual allowances, and their patient responsibility.”
Mary Wickersham, Vice President-Patient Financial Services, Avera Health: “From a market share standpoint, patients—depending on their insurance— they can choose to go to a competitor and if they have a bad financial experience, they may go across town to the competitor, because they feel like there's more focus on the billing experience than there used to be. There's a lot more scrutiny because of price transparency and people want to challenge everything, which is good, but I think there's just been that shift and the light is shining more on the financial side.
We have outside providers that come in and treat patients. The anesthesia group that we have, it's not Avera. But they're putting people to sleep in our hospital, and they don't understand that they're not Avera, so they get a separate bill from them and that doesn’t make sense.
But with the No Surprises Act, we're going to have to put their charges on our estimate, so the patient has that full picture—how are we going to figure all that out?”
Mary Neal, Assistant VP of Revenue Cycle, Ochsner Health: “Not every patient has the financial literacy or literacy in general to grasp even the most simple concepts sometimes, so that can make it harder on us to educate.
I think when you're speaking about the consumer experience in general, even taking healthcare out of it, we don't dissect the different pieces and parts and say, ‘Well, the care was great, but the billing part was just okay.’ You're evaluating that product or service as a whole.
If the financial piece is not where it needs to be, one could only assume this is representative of the level of quality of everything else that you're going to get.”
Wickersham: “There's an overarching misunderstanding in every community, they look at our charges and they're like, ‘Why are they so high? How can the hospital not be making money?’ There's this thing called contractuals. It's like there needs to be some big news special explaining healthcare, charges, contractuals, payer contracts, because people don't get that, and I wouldn’t understand it either unless I worked in it.”
Neal: “As much as we try to automate to lower the cost, the automation is only as good as the people who build it and validate it regularly.
It's difficult when you're trying to explain to a patient that maybe there was an error on their bill because not every single claim gets a human looking at it for accuracy before it goes out the door.
There's good, legitimate reasoning behind that, but patients don’t want to hear, ‘oh, this is wrong because it just ran through the machine, and this is what bill we sent you.’"
The OIG found that incorrect modifier usage led to $4.9 million in overpayments.
Now is the time to shore up your revenue cycle as some providers may need to pay for incorrect modifier usage.
According to the recent report by the OIG investigating instances of incorrect co-surgery and assistant-at-surgery modifier usage, 69 of 100 sampled procedural services did not meet federal requirements.
An additional review of 127 corresponding services found that 49% were noncompliant with federal requirements, as well.
The OIG reviewed a randomly selected sample of 100 services rendered by Part B providers between 2017 and 2019 with certain CPT procedural codes and a Medicare Physician Fee Schedule (MPFS) co-surgery indicator of 1 or 2. The reviewed procedures included spinal fusions, knee replacements, and endovascular repairs, among others.
Having an MPFS co-surgery indicator of 1 means co-surgeons could be paid, though supporting documentation is required to establish medical necessity for a two-surgeon procedure. Having an MPFS co-surgery indicator of 2 means co-surgeons are permitted and no documentation is required if the two-specialty requirement is met.
According to the report:
49 of the sampled services (71%) were reported without the co-surgery modifier
14 of the sampled services (20%) were reported without an assistant-at-surgery modifier
6 of the sampled services (9%) were duplicate services
The OIG estimates that the errors resulted in a total of $4.9 million in overpayments during the audit period.
These additional costs add further strain during a time of historic inflation levels and workforce challenges.
As hospitals try to navigate the COVID-19 crisis, inflation, labor shortages, and rising expenses, organizations are going to finish out the year in the red, according to the latest National Hospital and Physician Flash reports from Kaufman Hall.
To increase collections and build a stronger, more positive relationship with patients amid these struggles, revenue cycle leaders are putting the spotlight on the patient experience, but as staffing shortages hit organizations’ hard and patients’ length-of-stay grow, these goals seem more unattainable.
The average length-of-stay in hospitals has increased by about 19% for patients in 2022 compared to 2019, according to data from the healthcare consulting firm Strata Decision Technology.
These delays in hospitals’ ability to discharge patients, as well as the negative consequences on both patients and hospitals, was stressed in a recent report released by the American Hospital Association (AHA).
According to the AHA, delays in discharge result in hospitals and health systems undergoing additional pressure on an already overwhelmed workforce and reduce overall community access to care.
Additional costs for hospitals are also associated with delays in discharge, as they do not receive reimbursement for any costs associated with the extra days caring for patients in the hospital while patients wait to be discharged.
With hospitals’ expenses projected to have increased by $135 billion just in the last year, and 68% of hospitals ending the year operating at a financial loss, these additional costs add further strain during a time of historic inflation levels and workforce challenges.
“Delays in patient discharges create bottlenecks in the health care system, adding to the already overwhelming challenges facing our hospitals and caregivers. Temporary relief to overburdened hospitals and other providers will help ensure patients get the most appropriate care and will relieve stress on front-line health care workers,” said Rick Pollack, president and CEO of the AHA.
The AHA is asking Congress to establish a temporary per diem Medicare payment that would be targeted to hospitals to easy capacity issues. This would include acute, long-term care, rehabilitation, and psychiatric facilities and would be made for cases identified and assigned with a specific discharge code that falls under this type of long stays.
The patient financial experience and No Surprises Act are top of mind for revenue cycle leaders as we move into 2023.
As hospitals try to navigate the COVID-19 crisis, inflation, labor shortages, and rising expenses, organizations are going to finish out the year in the red, according to the latest National Hospital and Physician Flash reports from Kaufman Hall.
To increase collections and build a stronger, more positive relationship with patients amid these struggles, hospitals are putting the spotlight on the patient experience. While streamlining front-end and back-end operations are a must, there is a wrinkle that leaders have been struggling with: The No Surprises Act.
Novant Health's Senior Vice President of Finance, Geoff Gardner, spoke exclusively with HealthLeaders on the changes he sees for the patient financial experience considering the No Surprises Act and price transparency.
“In light of recent legislation around price transparency and surprise billing, it's critical that providers listen to their patients and find ways to engage that work for them,” Gardner said.
“Part of the reason we decided to implement new technology was because we wanted to optimize our billing experience on mobile devices. I'm sure we'll see this trend continuing—both at Novant Health and across health systems in general. Providers should be empowering patients with a digital-forward experience that helps patients understand their bills and how insurance benefits apply.”
As 2022 ends and revenue cycle leaders start to look toward 2023, technology is at the top of the to do list for a lot of leaders.
Adding in automation can be complicated, and revenue cycle leaders should look toward their peers when looking to seamlessly implement new technology.
From perfecting your workflows to collaborating with other departments, there are a few keys to success that revenue cycle leaders should keep in mind when looking to automate processes.
Jamie Davis, executive director of revenue cycle management at Banner Health, spoke with HealthLeaders about Banner Health's journey in implementing the use of AI, automating its revenue cycle management, and lessons learned from taking on such a large task.
"In full transparency, we tried to run first, and then we fell. We realized we needed to slow down a little bit, which was a great lesson learned," Davis said. "I think anyone who is trying to be innovative has those horror stories where something worked out really well in the boardroom and not so much in real life."
Banner Health has 30 hospitals, and the appropriate workflows weren't aligning. "So, we automated a dysfunctional workflow, and it ended up being more cumbersome to utilize the machine learning. It was a good learning experience—we did the fail-fast theory."
After stepping back, realigning its strategic planning, and partnering with IT, Banner's deployment process started to turn around.
"We ended up creating hierarchal scoring for all of the automation that we wanted to consider. On one side, we have the benefits: for example, net revenues, compliance, or full-time employee re-allocation. We would then weigh those scores and compare them to the complexity of the build: for example, how many process variants does it have? How many systems are in there?" Davis shared.
After gathering those scores, Banner would use a classic grid to determine automation that was low-effort, low-return, and high-effort, high-return. This hierarchical approach made all the difference for them.
"Once we did that, we applied a continuous improvement team member to have oversight and to help be that subject matter expert in the revenue cycle to make sure we aren't recreating core processes. And from there, our automation just went gangbusters," Davis said.
CMS' plan to streamline the prior authorization process would slash the amount of time spent chasing approvals and save providers billions.
The recently released prior authorization proposed rule would place new requirements on payers could save providers $15 billion in 10 years, according to CMS.
The rule, replacing a previous proposal from December 2020, takes aim at prior authorizations, which providers have long cited as a timewaster and resource-drainer.
By revving up technology-enabled prior authorization platforms and demanding that payers provide clear denial reasons and decisions within seven days (and in some cases 72 hours), the new proposal seeks to lessen the administrative challenges associated with pre-approvals.
The impact of the set of proposals, according to CMS’ estimates, would be enormous – underscored by a reduction of 213 million hours and cost-savings of more than $15 billion over the first 10 years, Part B News reported.
Part B News analyzed the data and found that the annual per-practice savings are estimated to be $19,524, and CMS projects that the nation’s nearly 200,000 physician practices would save more than $1 billion in aggregate during the first year. That number would rise to nearly $2 billion by 2035, assuming half of the country’s practices adopt the changes.
CMS is currently seeking comments on the proposed rule and its various policies, which would kick in Jan. 1, 2026, if the rule is finalized as proposed.
HHS proposed a new standard for attachments to support claims and prior authorization transactions.
HHS recently released a proposed rule that aims to standardize claims and prior authorization transactions under HIPAA.
According to the proposed rule, HHS seeks to adopt a set of standards for the electronic exchange of clinical and administrative data to support prior authorizations and claims adjudication.
In determining the necessity of a service as part of making a coverage decision, payers often require additional information that cannot adequately be conveyed in the specified fields or data elements of the adopted prior authorization request or claims transaction, the proposed rule said.
So, if this rule is adopted as proposed, the new standards would support electronic transmissions of this information, which would lighten the load for front-end revenue cycle staff by decreasing the amount of time and resource-consuming, manual processes used today to transmit this information.
This would facilitate better prior authorization decisions and claims processing, reduce burden on providers and plans, and result in more timely delivery of patient healthcare services, the rule said.
This is seen as a step in the right direction as the Medical Group Management Association's 2022 Annual Regulatory Burden Report says prior authorization requirements ranked as the top burden for providers.
According to the survey, 97% of respondents agreed that a reduction in regulatory burdens like this would allow their practice to reallocate resources toward patient care.
The AHA also echoed this sentiment and praised the HHS’ proposed rule.
The standard would apply to all providers who currently lack an efficient and uniform method of sending attachments, which can lead to provider burnout, slow down processing, and delay payments or patient care, the AHA said.
"The AHA supports establishing a standard for attachments to reduce the administrative burdens facing clinicians, and we look forward to providing robust commentary after analyzing the rule's specifics," Terrence Cunningham, AHA's director of administrative simplification policy, said in a release.