The HealthLeaders' Revenue Cycle Exchange is underway this week in Carlsbad, California.
Payer compliance and workforce are top of mind for the executives attending this week's HealthLeaders Revenue Cycle Exchange. As regulatory burdens and staffing shortages put strains on their revenue cycles, leaders agree they need to start thinking outside the box and working together.
When it comes to payer compliance, the leaders at the event say there are two major players that cause the most headaches for them: United Healthcare and Blue Cross Blue Shield.
When deciding how to work with these payers, there are a few strategies the leaders shared that work for them.
"Blue Cross always asks us to pull medical records. We don’t have the capacity to do it ourselves, so we requested that they send a representative down to do it themselves. And they did," Jeanne Stokes, CBO Manager at Ironwood Cancer and Research Centers, said.
While working with payers has been the biggest headache discussed so far, Christine Migliaro, vice president, revenue cycle operations at Northwell Health, reminded everyone that between payers, patients, and our own coworkers, "what makes our job complicated is what makes our jobs great.”
On the same note, Migliaro discussed in depth the importance of building a strong revenue cycle team when workforce challenges seem to be at their peak. "Your culture can’t be fake, it needs to be who you are," she says.
Even more important than a positive, honest culture is collaboration across the entire team. "I played many sports growing up, and they all prepared me for my current role because revenue cycle is the ultimate team sport," Migliaro said.
"We have 8,000 end users in our revenue cycle that do not report to us, and everything they do affects me. Partnership is really needed to get something done,” Migliaro said.
Discussion sessions were also held that focused on robust conversations about the No Surprises Act, including price transparency and good-faith estimates, and improving the patient financial experience.
Stay-tuned for more coverage of this event which will include “ideas presentations” from prominent leaders such as Michael Gottesman, assistant VP of revenue cycle at Northwell Health, and Allyson Keller, executive director at Piedmont Healthcare.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
Join us for the next HealthLeaders Revenue Cycle Exchange!To inquire about attending a HealthLeaders Exchange event, email us at exchange@healthleadersmedia.com.
If you experienced a recent surge of denials for observation visits, a payer error could be at fault.
Four Medicare administrative contractors (MAC) have announced that they improperly denied claims for hospital inpatient and observation care codes and are working on the problem, according to Part B News.
The error affects claims for observation visits performed on or after January 1 and is triggered by the place of service (POS) on the claim.
According to Part B News, First Coast Service Options and Novitas are working on an error that denies claims for initial and subsequent hospital visits reported with the POS for services in the on campus-outpatient hospital setting.
Palmetto GBA and WPS Government Health Administrators identified a similar problem with a wider impact. Their systems denied claims for discharge day management services in addition to initial and subsequent hospital visits, and off campus-outpatient hospital, emergency room, and comprehensive outpatient rehabilitation facility visits.
Don’t resubmit claims for improperly denied observation services to these MACs, Part B News warned. According to the announcements issued to date, the MAC will automatically adjust claims affected by the problem, so no revenue cycle action is necessary.
If your revenue cycle team resubmits the claims, it could trigger duplicate claim denials or improper payments.
More and more studies are pointing to the growing concern of denials for revenue cycle leaders as more pressure is put on these leaders to help increase their bottom lines.
Revenue cycle leaders must ensure their teams monitor denials of all types. Regularly monitoring denials helps revenue cycle leaders and their teams identify common reasons for rejections, develop solutions to prevent them, and ensure timely reimbursement.
The director of CDI/utilization review at Avera Health reviews two key areas needed to shore up clinical validation denials.
Denials management has become a major area of concentration for revenue cycle leaders.
In fact, denials rose to 11% of all claims last year, up nearly 8% from 2021. That 11% rate translates into 110,000 unpaid claims for an average-sized health system, according to the report.
While prior-authorization denials were at the heart of the cost increase in that study, there’s another area revenue cycle leaders should place their focus to help ease the denials burden: clinical validation denials.
Clinical validity denials occur when there is a lack of clinical evidence in the patient chart to support a billed diagnosis. Claims may be denied, for example, if they lack clinical criteria necessary to support a diagnosis, contain inconsistencies, or do not meet payer-specific diagnostic criteria.
In most revenue cycles, the CDI staff is responsible for reviewing documentation to ensure that it supports reported diagnoses and for collaborating with staff to update documentation that is insufficient to support medical necessity.
Because your CDI teams have such a heavy hand in documentation review, they make it the perfect place to start when shoring up clinical validation denials.
Stacy Reck, director of CDI/utilization review at Avera Health, recently shared strategies for helping to prevent these denials before they happen and how to manage MS-DRG downgrades and financial takebacks.
A key defensive strategy for preventing denials is provider education, Reck said in a recent HCPro webinar. This can involve bringing data on the financial impact of documentation inconsistencies to providers and explaining how they can be prevented.
For example, Avera Health tracked and analyzed claims for acute respiratory failure that were denied due to a lack of explicit documentation of symptoms to support medical necessity. “If the patient has acute respiratory failure, you can’t only use phrases such as ‘patient resting comfortably.’ The patient may be resting comfortably for a period, but this doesn’t support a diagnosis of respiratory failure.”
In this instance, the CDI staff were able to effectively reduced denial rates for respiratory failure and other similar diagnoses by educating providers on the effective use of key clinical terminology to clearly explain the patient’s current health status.
“Clinicians want to document better and don’t want to get a query,” said Reck. “They may also have their own ideas for preventing documentation inconsistencies such as incorporating prompts into their EMR [electronic medical record].”
Making sure your middle revenue cycle leaders collaborate and continue to be educated on regulatory changes will help to improve on these denials before they happen.
But what if these denials still happen?
It’s essential for revenue cycle leaders to understand that these denials are even happening outside of the claims process and after payment, usually through MS-DRG downgrades, Reck told HealthLeaders.
Pictured: Stacy Reck, director of CDI/utilization review at Avera Health. Photo courtesy of LinkedIn
“These financial takebacks are often occurring under the radar because the business office staff doesn’t know about the denial because the account is at a $0 balance,” Reck says.
Collaboration between your CDI teams, utilization review, and the business office staff is essential to understand the current state of clinical validity denials at your facility, Reck said.
Reck says that revenue cycle leaders can’t assume that appealing a denial or MS-DRG downgrade will result in the payer responding back to you.
“In working through an internal, home-grown tracking tool for clinical validity denials, we identified a black hole with cases in which we never heard back from the payer. In following up, we often heard, ‘We didn’t get the appeal, and now you are past your timeframe to appeal,’” Reck said.
“We knew this was incorrect because we document fax confirmations on all our appeals. The follow up work for these denials needs to be discussed in your facility to determine who is best to perform a follow-up or these cases will often go through as denied, and the payer will recoup the difference of the MS-DRG on another remit,” Reck warned.
Tracking the volume of these denials is essential to understanding trends specific to certain diagnoses, MS-DRGs, and payers, Reck told us. Tracking these types of denials supports the program of work by showing that without dedicated staff managing appeals, there can be a significant loss in revenue for a health system.
The district court recently remanded remedy decisions to HHS for its underpayments related to the 340B drug pricing program.
After experiencing several key wins throughout their long legal battle with HHS, the American Hospital Association (AHA) and other industry plaintiffs were disappointed by the January ruling where a district court judged remanded HHS the question of how to repay 340B hospitals.
According to the AHA, this decision caused the repayments to be even further delayed—and a recent letter penned by the group outlines five ways the group says HHS can expediate the administrative process and avoid further legal challenges.
In the letter, the AHA calls for HHS to:
Repay each 340B hospital the full amount that was unlawfully withheld between January 2018 and September 2022
Repay each 340B hospital promptly
Not impose a prospective remedy
Pay hospitals interest on its underpayments until they are fully repaid
Not recoup funds from the hospital field to achieve budget neutrality
"As the AHA has stated before, we are willing to work with HHS to assure a fair and equitable resolution of these issues, which have already taken far too long to resolve, at great cost to the entire hospital field," the AHA said.
"Working together, HHS and the AHA can develop a fair and administrable remedy that avoids further legal or administrative delay."
This is just the latest drama surrounding 340B payment cuts. The long legal battle between HHS and hospital groups stems from the nearly 30% cut to hospital reimbursement under the 340B program in 2018.
After a 2022 court ruling, CMS restored 340B reimbursement to the pre-2018 method of average sales price +6% for fiscal year 2023. However, to maintain budget neutrality for 2023, the agency implemented a 3.09% reduction to payment rates for non-drug services.
"Henry Ford Health system and a lot of folks rely on 340B discounts and other mechanisms like disproportionate share payments. We're a big teaching institution, so a lot of these special payments that we do in order to teach the healthcare leaders of the future or make sure that we can take care of vulnerable patients are extremely important," Damschroder said.
"So that is an area that we and others are actively—in our advocacy—ensuring that these programs stay intact or evolve to a place that enhances the programs for the people that were trying to care for," said Damschroder.
Revenue cycle leaders should have their teams stay up to date on these regulations to ensure their organization understands how these changes to reimbursement will affect their organizations throughout the year.
Avera Health's billing services officer details the system's pain points and what's ahead for 2023.
Economic hardships have been increasing each year for hospitals. Even worse, 2022 was the worst year financially for hospitals and health systems since the COVID-19 pandemic began, and revenue cycle leaders are not off the hook.
Declining operating revenue for health systems, payers squeezing even harder on denials, and a fundamental shift in the workforce have been creating trying times for our revenue cycle leaders.
These hardships are pushing leaders to consider changes in 2023 and as Amanda Schutz, billing services officer at Avera Health says, remedying staffing challenges and implementing automation will be a priority for the health system this year.
Staffing has been a primary challenge for Avera Health’s revenue cycle in the last few years, Schutz says. To stay competitive, Avera has had to allow for more flexibility during working hours and grant staff the ability to work from home.
To remedy further staffing challenges, Schutz plans to advocate for the revenue cycle to make greater financial investments in automation for 2023. “That could be through AI, bot technology, or any technology that allows us to be more efficient in our day-to-day work,” she says. “With the cost of staff, we have to get more creative when it comes to automation.”
Pictured: Amanda Schutz. Photo courtesy of LinkedIn.
“I’m excited to be part of our automation/technology discussion and decisions at Avera. This is an area that we need to continue to dig into and decide what technology will allow our revenue cycle to run more efficiently,” Schutz says.
Schutz will be joining us at this month’s Revenue Cycle Exchange to talk through these pain points and more.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
Prior authorizations and price transparency will be a main focus of advocacy for 2023.
Each year the American Hospital Association (AHA) releases an advocacy agenda focusing on key areas in need of “critical support” for hospitals and health systems, and this year, quite a few key areas will be focused on your revenue cycle.
“Hospitals and health systems are dealing with unprecedented challenges as they manage the aftershocks and aftermath of COVID-19. These include historic workforce shortages, soaring costs of providing care, broken supply chains, severe underpayment by Medicare and Medicaid, and an overwhelming regulatory burden, just to name a few,” the AHA said.
To address these challenges, this year’s agenda is broken down into four main areas of action:
Ensuring access to care and providing financial relief
Strengthening the healthcare workforce
Advancing quality, equity, and transformation
Enacting regulatory and administrative relief
Most of these key areas include specific agendas related to the revenue cycle.
The group says it wants to enact technological, legislative, and regulatory solutions to reduce administrative waste by streamlining prior authorization requirements and processes for hospitals so that clinicians can spend more time on patients rather than paperwork.
It also plans to support price transparency efforts by ensuring patients have access to the information they seek when preparing for care, including cost estimates when appropriate, and creating alignment of federal price transparency requirements to avoid patient confusion and overly burdensome duplication of efforts.
When it comes to surprise billing, the AHA says it plans to ensure that regulations to implement surprise medical billing protections for patients do not inadvertently restrict patient access to care.
Social determinates of health capture also made the agenda. The AHA says it will promote approaches to account for social risk factors in quality measurement programs where appropriate to ensure equitable performance comparisons and payment adjustments, and promote alignment and standardization of approaches to collecting, analyzing, and exchanging demographic and health-related social need data across federal agencies.
The AHA says it will work with Congress, the administration, regulatory agencies, courts, and others to positively influence the public policy environment for patients, communities, and the healthcare field.
There is much more than just revenue cycle-related challenges being addressed. The hospital association is also placing a focus on workplace violence, Medicare residency slots, the nursing shortage, and workforce diversity. Read more about those initatives here.
A new survey highlights the importance of digital options in improving the patient experience.
Does your revenue cycle have poor digital engagement options? Well, it might be costing you patients, a new survey shows.
At a time when a positive patient experience is playing a heavy role in overall reimbursement, a new report from Accenture says patients are becoming more comfortable switching providers when their current one isn’t meeting their needs.
According to the report, many patients are finding it difficult to navigate their care journey.
78% of patients that switched health systems cite ease of navigation factors as the reason for leaving. These factors include difficulties in doing business, bad experiences with front-end staff, and inadequate digital solutions, the report says.
The report, which surveyed 10,000 US consumers between October and November 2021, also highlighted the need for technology in the revenue cycle as digital engagement played a large role in provider loyalty.
According to the report, nearly 80% of “highly digital” patients are likely to stay with their providers. This is more than 20% greater than all other digital engagement categories, the report says.
Although the report doesn’t cite specific digital engagement options, digital front doors, streamlined patient portals, and digital billing options have all been linked to a more positive patient experience within the revenue cycle.
Now, The American College of Emergency Physicians, American College of Radiology, and American Society of Anesthesiologists are showing support to the TMA as the groups filed a joint amicus brief with the court.
The groups say the issues outlined in the TMA’s suit hinders physicians and facilities from engaging in fair contracting negotiations with insurers, which could threaten their ability to operate and may result in patients losing access to in-network care.
The initial administrative fee for the IDR process was set at $50 and it was announced in October 2022 it would remain at $50 for 2023, but in January, the agencies revealed a 600% hike in the fee due to increasing expenditures in the IDR process, among other reasons.
"The steep jump in fees will dramatically curtail many physicians’ ability to seek arbitration when a health plan offers insufficient payment for care," the TMA said.
The amicus brief also outlined the flawed qualifying payment amount (QPA) process.
The medical societies say the methodology for calculating the QPA artificially deflates the QPA by:
Establishing each contracted rate as a single data point
Excluding incentive-based and retrospective payments
Including rates for physicians in different specialties
Allowing third-party administrators to determine the QPA based on contracted rates recognized by all self-insured group health plans administered by the third-party administrator
"The inaccurately calculated QPA compounds the defects of the biased IDR process under the August final rule, which favors the QPA and empowers insurers to significantly reduce their in-network rates or terminate in-network agreements altogether," the groups say.
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 January, including ICD-10-CM code updates and the OIG’s Work Plan.
The PHE is seeing an end.
The COVID-19 public health emergency (PHE) will end on May 11 according to a policy statement released by the Office of Management and Budget opposing House resolutions that would end the emergencies immediately if passed.
This will have implications on reimbursement for the revenue cycle, so stay tuned for future coverage.
New diagnosis codes were release, effective in April.
CMS should bolster its oversight of ASP data, the OIG says.
The OIG published a review of CMS’ oversight of manufacturer-reported average sales price (ASP) data, as the data is used to help calculate Part B payments and therefore there are concerns about the impact of inaccurate data on Part B spending.
The OIG found that there were gaps in CMS’ oversight of this data, as CMS’ quality assurance procedures did not include checks to ensure the accuracy of manual processes employed to analyze the data used to calculate Part B payment amounts.
The OIG also found CMS does not leverage its data collection system to produce reports that could monitor ASP data quality and aid in oversight. Because of invalid or missing data, CMS had issues calculating ASP-based payment amounts for a small amount of drug codes, and that can often lead to higher drug payment amounts for Part B drugs.
The OIG also found that 24% of drug codes were missing ASP data for drugs within that code in at least one quarter from 2016-2020. The OIG recommends CMS determine a strategy to strengthen its internal controls for ensuring the accuracy of Part B drug payments. CMS concurred with the OIG recommendations.
CMS slid in an update to the OPPS.
CMS published Medicare Claims Processing Transmittal 11801, which updated tables 5, 6, and added table 20 in the OPPS rule. This change updates the pass-through status of five devices that will now have an extended pass-through status for a one-year period beginning on January 1, 2023.
OIG updated its Work Plan.
The OIG updated its Work Plan and will be setting its sights on the following new items:
The Texas Medical Association (TMA) is suing HHS for the fourth time, this time for its 600% price increase pertaining to an aspect of the No Surprises Act.
That didn’t take long.
The independent dispute resolution (IDR) process has gotten more expensive for healthcare organizations, and now groups are demanding a reverse from HHS.
As HealthLeaders previously reported, it was announced that the nonrefundable administrative fee due from each party involved in any IDR payment dispute that goes to arbitration increased from $50 to $350. This 600% increase began January 1.
Revenue cycle leaders are trying to find ways to increase their bottom lines for 2023, and this news was a step in the wrong direction, especially for smaller healthcare organizations. At the time, we mentioned that this price hike may put organizations in a losing situation as they consider whether to formally dispute a payer’s proposed out-of-network payment amount.
The TMA says its newest lawsuit against federal agencies challenges the steep administrative fee hike that will strip many physicians and healthcare providers of the arbitration process that Congress enacted. These fees are "arbitrary and capricious, contrary to the law, and in violation of notice and comment requirements," TMA said in a statement.
The initial administrative fee for the IDR process was set at $50 and it was announced in October 2022 it would remain at $50 for 2023, but in January, the agencies revealed a 600% hike in the fee due to increasing expenditures in the IDR process, among other reasons.
"The steep jump in fees will dramatically curtail many physicians’ ability to seek arbitration when a health plan offers insufficient payment for care," the TMA said.
"The problem is that many payment disputes in these cases amount to less than the fees physicians would have to pay to dispute the unfair payments," said TMA President Gary W. Floyd, MD, in a statement.
"Why would doctors and providers pay the $350 nonrefundable administrative fee to arbitrate a $200 or so payment dispute with a health insurer? The fees deny physicians the ability to formally seek fair payment for taking care of our patients, and that’s just wrong," Floyd said.
The suit lists two radiology groups as plaintiffs: the Texas Radiological Society and Houston Radiology Associated. These groups bill small value claims, so they will be particularly hurt because most claims billed are less than $350, according to the suit.
Although the fee hike takes the focus of this suit, the TMA also disputes the rules’ narrowing of the law’s provisions on “batching” claims for arbitration, which Congress authorized to encourage efficiency and minimize costs in the IDR process, the TMA said.
As mentioned, this is the fourth suit filed by the TMA regarding nuances found within the No Surprises Act. Catch up on HealthLeader’s coverage here.
