There is an obvious need for patient payment platforms, but revenue cycle leaders aren't letting vendors off the hook.
Revenue cycle leaders are in search of ways to better secure revenue by bolstering their technology, and if perfecting and expanding online payment options aren’t on the radar, a big opportunity could be missed. And while this is area of need for revenue cycle leaders, vendors need to better perfect their offerings.
Receiving payments at the hospital is still the predominant way consumers settle medical bills, but according to a new study that’s changing as awareness of online portals and unified digital platforms grows.
The research found that nearly 30% of the entire sample used an online portal to pay a medical bill in the past year. “In the same timeframe, 36% of consumers paid bills in-person at a provider’s office or healthcare facility. That gap of roughly 7 percentage points is closing faster as more consumers become aware of new online payment options,” the study said.
The heat is not off vendors, though, as providers have rightly high expectations for the tech.
While most providers have seen an implementation of new patient payment solutions in the past five years, the platforms still have room for improvement for both providers and patients, according to a separate survey recently analyzed by HealthLeaders.
In that study, 650 providers in the U.S. shared their experiences with patient payment solutions and what more they want out of the platforms.
Only 58% of respondents reported high satisfaction with their current patient payment systems, with 30% saying the implementations were not successful.
Revenue cycle leaders know that patients expect payment methods that are both convenient and efficient, but that doesn’t mean any and all payment platforms are worth the time and effort.
Providers also want to make their own lives easier, which includes fully integrating patient payment solutions with their EHR—something only 33% of respondents reported having. More than half (58%) said the seamlessness of their current systems could be improved.
The director of revenue cycle process and system support at Moffitt Cancer Center shares his top recruiting tips.
The revenue cycle workforce wasn't immune to the drastic changes happening in healthcare over the last several years. An entire office floor that previously housed a revenue cycle department is now silent and desolate as most staff have been working remotely for years at this point.
Working remotely has been a success for most organizations and is now a permanent work model, and since recruiting an elite revenue cycle team is still a priority, the way organizations find that talent has changed too.
Bill Arneson, director of revenue cycle process and system support, at Moffitt Cancer Center, recently chatted with HealthLeaders about his strategy for recruiting the best talent for his revenue cycle technical team.
After several years of recruiting and development, since January 2023, Arneson says his teams now oversee all revenue cycle automation systems, business rules, and all operational reporting for the hospital, the physician group, and the clinical trial revenue cycle.
Arneson says that in the month of January alone, his team of 22 automated over 360 full-time employees and 689,000 tasks, “which as we calculate out, saves us about $982,000 per month,” he says. “Based on what we accomplish, I put my team in a pretty elite tier, if not one of the best in the country,” he says.
So how did Arneson develop such an accomplished team? Read on to find out. This conversation has been edited for length, but you can listen to the entire conversation here.
HealthLeaders: Hospitals were struggling financially in 2022 as they tried to navigate inflation and labor shortages among many other challenges. Because of this, Moffitt took a unique approach to build up the revenue cycle technical staff. Can you tell us how that came about?
Bill Arneson: Moffitt has been very big in creating efficiencies and choosing process improvements or automation over hiring people for several years. The first answer is never to just hire more people. I don't think that's the first thing any healthcare system wants to do, luckily, I know how to accomplish that.
I need some smart analyst developers or software architects. But I also know we're not going to win any bidding wars with Google or Amazon or some consulting firms. So, I focus on what is in my control. I can control the culture of my team, I can control how good of a recruiter I am personally, and I can control what kind of leader I am. So, the number one thing we try to do is foster a culture that people want to join. If the people love your team, we'll help you recruit good people, and they will stay.
This enables us to get some of the stars who could go somewhere else and make more, but honestly, they would rather have a great working environment and have a great work-life balance then go somewhere else and make a little bit more. So that's one of the things we try to leverage.
We also try to, as I call it, ‘recruit the diamonds in the rough.’ I specifically search for stars in other departments that are not technical people, but who have some raw technical skills or interest.
For example, that person who is over in patient access and they are excellent in Excel. They're the one always digging into the reports. Chances are they could easily transition into a reports person with some training. Another example is the gamer. Avid gamers are great because they're usually very techie people. They might not have pursued an IT career, but they're always into the latest gadgets. Also, people that are going back to school for IT degrees are great candidates to seek out.
HealthLeaders: What criteria do these recruits have to meet before they can be hired on the revenue cycle technical team?
Arneson: It is not a hardline of requirements. We'd like to keep requirements vague because the revenue cycle is such a diverse group of tasks. You need people from across the spectrum, as far as backgrounds and talents.
The number-one thing I look for is emotional intelligence, which I admit can be very hard to identify, especially with external resources. But honestly, they have to be a good team member. They must be able to be an adult and work through problems. I'm a big advocate of peer interviews during the hiring process. I'm only going to have to work with the people one or two hours a week, while their peers must work with them eight hours a day.
Along with that, they need the technical aptitude to fit the role because there will be some very high-level technical roles that they just simply aren't qualified for. So, recruits have to be at a level that allows them to do the technical part of the role too.
We also like then to have the traditional healthcare or revenue cycle understanding, but then again, we've also chosen technical experience over revenue cycle knowledge. For example, we’ve brought over engineers from Citigroup that turned out to be wonderful and amazing, and once you're a software developer, you can apply those skills across the board.
So, as far as qualifications, it really depends, but I would say those are the top three I look for: emotional intelligence, a good team member, and enough technical skills to start the role.
HealthLeaders: Do you have any other unique recruiting techniques that you can share with other organizations?
Arneson: You have to make recruiting part of your job as a revenue cycle leader. You can't just rely on HR or talent teams. I've found a lot more people through building a network of my own than anything else. Also, you have to assess where your budget is at. If you can’t afford to hire the star IT people, then you have to commit to developing them. Ask yourself, are you the New York Yankees with unlimited money? Or are you the Tampa Bay Rays who have to work the farm system and develop players?
I've had people from both: I've brought in people from Epic, Cerner, and Siemens, as well as those home-grown people. I just find the best talent I can, you know the emotionally intelligent good team members, and then tweak it along the way until they find their groove.
I could go through the list of how I hired all of my people, but most importantly, it's never a set it and forget it. Once you hire someone, you have to constantly be thinking how you can bring them in and find new skill sets. People's interests change over time as well so be prepared to constantly be growing the team members that you already have. That will really help you retain and grow your staff so you’re not always recruiting.
HealthLeaders: What is next for Moffitt’s recruiting? Are there other areas outside of the revenue cycle that these strategies may work for?
Arneson: I think everyone's resources got completely out of whack the last few years. And just weathering that storm, we have all done a phenomenal job. But anyone who wants the top talent has to ignore all the traditional boxes and focus on what it takes to be successful on your team. If you look at your staff that have been successful, there is a certain skill set that you can attribute across the board that those people have. That's the sort of stuff you need to be looking to develop.
And keep in mind, developing staff will not always be a straight path. I don't think very many people in their careers have a straight path from college to their dream job. It honestly takes a lot of work by the leadership to build the culture teams want, and need, to be successful.
A recent report calls out the winners and losers of price transparency adherence.
The Semi-Annual Hospital Price Transparency Compliance Report, recently published by PatientRightsAdvocate.org, analyzed 2,000 of the nation's largest hospitals from December 10, 2022 through January 26, 2023 to determine price transparency compliance.
Compliance was based on the inclusion of machine-readable files for all items and services, as well as price display of the 300 most common shoppable services.
As HealthLeaders previously reported, the newest findings reveal a modest increase in compliance percentage since the previous report in August 2022, with 24.5% of hospitals (489) now compliant, compared to 16% last year.
While this shows that 75.5% of hospitals are still not complying with the price transparency rule, the report names three major hospitals that are.
According to the report, among the 489 compliant hospitals, there were three hospitals that posted “exemplary” files that were easily accessible, downloadable, machine-readable, and included all negotiated rates by payer and plan:
MetroHealth Medical Center in Cleveland, Ohio
NorthSide Hospital Atlanta in Atlanta, Georgia
NorthSide Hospital Cherokee in Canton, Georgia
In contrast, some of the largest health systems in the country continue to be some of the biggest perpetrators of the law.
None of the hospitals owned by HCA Healthcare, Tenet Healthcare, Christus Health, Providence, Bon Secours Mercy Health, UPMC, Mercy Health, UnityPoint Health, and Avera Health were found to be compliant, according to the report.
Revenue cycle leaders agree they need to unite against one common enemy: the payer.
Editor's note: This article appears in the June 2023 edition of HealthLeaders magazine.
Payer compliance was a hot topic for the revenue cycle executives attending the recent HealthLeaders Revenue Cycle Exchange in Carlsbad, CA. Regulatory burdens and never-ending denials are putting massive strains on revenue cycles, and leaders agree they need to unite against one common enemy: the payer.
When it comes to payer compliance, revenue cycle leaders agree there are two major players in the industry that cause the most headaches for them right now: United Healthcare and Blue Cross Blue Shield (BCBS).
According to a poll of the 35 leaders conducted at the event, 44% of attendees chose both United Healthcare and BCBS as the most difficult payers to work with. These results were interesting as other payers came in far behind at 5% for Aetna, 5% for Humana, and 0% for Cigna.
So why these two payers? According to the leaders, United Healthcare and BCBS generally have complicated, multi-tiered structures and rules that seem to always be changing, regardless of their contracts.
Unlike Medicare, which has standard, heavily documented rationales and processes for denials, appeals, and audits, almost anything goes when it comes to commercial payers. Each payer organization will have different rules and processes, and payers’ manuals and bulletins aren’t always easy to locate.
“For us, it's really about new policy changes that they try to impose throughout the year and in the mid-contract period,” Patrick Wall, vice president of revenue cycle at St. Joseph's Candler, said to the group.
Even when policy changes spring up out of seemly nowhere, the leaders agreed that sometimes the administrative burden alone is too much. For example, one change BCBS has made is a substantial increase in the number of medical records it requests to pay a claim.
All this back and forth means that staying compliant with payers has been a burden on their workforce and themselves. With already strained staff it can be hard to find extra hands, and money, to keep up.
“I spent so much time and money in the last four years on legal fees and going through arbitration processes, and I spend a lot of time really holding payers to our contracts. Because we don't have a lot of protections like a lot of health systems, there's a lot of competition in our market,” Wall said.
UnitedHealthcare and BCBS aside, payer relationships are hard to navigate in general, the revenue cycle executives said.
The relationship between a provider and a payer organization rests on proactive communication—like any business relationship does—but what if that relationship seems one sided?
“The house always wins, and that's what the payers are. They hold a lot of the power, and they can take the ball and go home, especially in a city like Atlanta where there's four or five other systems competing for that book of business,” Derek Dudley, AVP of revenue cycle operations at Wellstar Health System, said at the event.
“When either side has too much control, it's hard to have that 'work together' kind of relationship,” Dudley said.
“We're trying though, and we all want to reach out to our payer partners and ask, 'how can we be better partners for you?' In turn, we want them to ask, 'how can we be better partners in working towards that?' But that level of dialogue is sometimes difficult,” Dudley said.
Aside from mending the payer-provider relationship, what else can providers do to strengthen payer compliance? Revenue cycle leaders agreed that having a robust contracting team and frequent joint committee meetings can make a big difference.
“We have a very strong contracting arm within our organization,” Chris Johnson, vice president of revenue cycle management at Atrium Health, said.
Some organizations even have routine have meetings with all of their major payers, such as joint review committee meetings and operating committee meetings, to review issues and organizational impacts.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
Want to hear more about the payer-provider relationship? You are invited to a HealthLeaders Community Call, “Payers Will Be Your Partners or Owners: Get Ready,” on Tuesday, February 28 from 1:00-1:30 pm EST, with Paul Keckley, author of the Keckley Report and one of the industry’s foremost policy and strategy experts. To RSVP, please email Abby Mathis at amathis@healthleadersmedia.com.
Join us for the next HealthLeaders Revenue Cycle Exchange!To inquire about attending a HealthLeaders Exchange event, email us at exchange@healthleadersmedia.com.
Patient experience is rightfully important to leaders, so is your hospital know for high-quality billing practices, or is it falling short?
At a time when a positive patient experience is playing a heavy role in overall reimbursement, and much of the billing process is shifting to patients who do not understand healthcare billing language, revenue cycle leaders are on the line to perfect their processes.
According to the Lown Institute, there are 15 hospitals that all received “A” grades from the organization in social responsibility for their patients and that have policies disallowing egregious billing practices.
California and Pennsylvania take the lead with the number of hospitals on the list. How did your organization fair?
The hospitals with “A” grades in social responsibility and billing quality in alphabetical order are:
Eden Medical Center, Castro Valley, CA
The Johns Hopkins Hospital, Baltimore, MD
Ochsner Medical Center—Northshore, Slidell LA
OHSU Hospital and Clinics, Portland OR
Ronald Reagan UCLA Medical Center, Los Angeles CA
St. Anthony Community Hospital, Warwick NY
St. Joseph Hospital, Eureka CA
Stanford Health Care —Valleycare, Pleasanton CA
UCSF Medical Center, San Francisco CA
United Medical Center, Washington DC
University of Mississippi Medical Center, Jackson MS
The AMA and CMS recently released new procedure codes for both your inpatient and outpatient coding teams.
As revenue cycle leaders work hard to avoid denials, payers won’t be afraid to deny your claims for coding errors. Keeping your directors and managers up to date on coding changes is key for proper and timely reimbursement.
For example, new codes will be added for aortic occlusions, spinal destruction procedures, and bone marrow transfusions. Several codes will also be added for the administration of newly developed immunizations.
Around the same time, the AMA’s CPT editorial panel released 20 new CPT codes. These new codes, along with two revisions, are mainly for cardiovascular procedures. These CPT codes will take effect July 1 and will be published in the 2024 CPT Manual.
Most of the new CPT codes pertain to cardiovascular procedures, such as percutaneous transcatheter thermal ablation of nerves, implantation and removal of a dual-chamber leadless pacemaker, and implantation of a superior and inferior vena cava prosthetic valve.
Elizabeth Ward, the CFO for Tidelands Health, a South Carolina-based healthcare provider with over $300 million in total revenue—agrees on the importance of proper documentation capture in the revenue cycle.
“[Something that I’ve helped my teams understand is] the importance of documentation and how that documentation is translated into codes that allows us to be paid for our services and care,” Ward previously told HealthLeaders.
“If you're documenting and coding well, it not only helps to get paid for what you do, but it also helps in your quality scores, and how you're looked at as a physician by CMS and other payers,” she said.
Because coding occurs mid-cycle, it provides an opportunity to catch errors introduced earlier in the process, as well as preventing similar errors in the future.
118 leading medical societies united to defend proposed prior authorization reforms.
The organizations, spanning from the American Medical Association to The Alaska State Medical Association, sent a letter to CMS urging it to finalize proposed prior authorization reforms that target the inappropriate use of authorization requirements by Medicare Advantage plans which, the organizations say, delay, deny, and disrupt the provision of medically necessary care to patients.
"Physicians appreciate the efforts of CMS to address the significant and multifaceted challenges that prior authorization requirements pose to Medicare beneficiaries and physicians," said American Medical Association President Jack Resneck Jr, in a recent press release.
"We applaud CMS for listening to physicians, patients, federal inspectors, and many other stakeholders, and recognizing a vital need to rein in Medicare Advantage plans from placing excessive and unnecessary administrative obstacles between patients and evidence-based treatments," Resneck said.
According to the letter, reforms proposed by CMS must be implemented amid mounting evidence that Medicare Advantage plans are delaying or even preventing Medicare beneficiaries from getting optimal care, resulting in alarming effects on patient health.
Because of this reason and more, the MGMA told HealthLeaders that the organizations have four key asks of CMS:
Finalize many of the prior authorization proposals in this rule that address long-established concerns
Apply the proposed clinical validity and transparency of coverage criteria policies beyond the current scope to include prescription drugs
Establish and implement an oversight plan that will hold plans accountable for noncompliance
Include additional prior authorization reforms in future rulemaking, such as eliminating step therapy, requiring gold-carding programs, and exempting medical groups participating in value-based models from prior authorization requirements
In the letter, the organizations pointed to three studies highlighting the prior authorization burden. According to the letter:
A recent survey found more than nine in 10 physicians (93%) reported care delays while waiting for health insurers to authorize necessary care. More than four in five physicians (82%) said patients abandon treatment due to authorization struggles with health insurers, and more than one-third (34%) of physicians reported that prior authorization led to a serious adverse event, such as hospitalization, disability, or even death, for a patient in their care.
The OIG found that Medicare Advantage plans improperly applied Medicare coverage rules to deny 13% of prior authorization requests and 18% of payments, in some cases ignoring prior authorizations or other documentation necessary to support the payment.
A Kaiser Family Foundation analysis found Medicare Advantage plans denied two million prior authorization requests in whole or in part, representing about 6% of the 35 million requests submitted in 2021. While about 11% of denials were appealed, the vast majority (82%) of appealed denials were fully or partially overturned, raising serious concerns about the appropriateness of many of the initial denials.
Building on that proposed rule, CMS released another proposal to strengthen prior authorization protections for patients, requiring: a granted prior authorization approval remain valid for an enrollee's entire course of treatment; Medicare Advantage plans to annually review utilization management policies; and coverage determinations to be reviewed by professionals with relevant expertise.
"Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health," said Resneck. "To protect patient-centered care for the 28 million older American that rely on Medicare Advantage, physicians urge CMS to finalize the proposed policy changes and strengthen its prior authorization reform effort by extending its proposals to prescription drugs. We stand ready to continue our work with federal officials to remove obstacles and burdens that interfere with patient care."
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.
