Review 3 Takeaways from the 2022 HealthLeaders RevTech Exchange.
Editor's note:This article appears in the March 2023 edition of HealthLeaders magazine.
Revenue cycle leaders face a dilemma: Either automate or risk having someone else do it for them. Once on the path to automation, leaders are faced with a set of balances and decisions that can either optimize or diminish the result.
Balancing automation and technology, along with workforce and strategy, were top of mind for the executives attending the 2022 HealthLeaders RevTech Exchange in Boston.
It's no question that automation is inexorable. But how it is deployed, and how the team shifts because of it, were among the connecting points at the event, along with these three takeaways:
Don't pave your goat path
Technology can support revenue cycles in centralizing and organizing data, allowing for greater transparency and performance, but while technology and automation are necessary, it doesn't work miracles.
As Derek Dudley, AVP of revenue cycle at Wellstar Health System said, "don't pave your goat path," an ages-old axiom for not applying new technology on top of a winding, bumpy process.
The use of technology and automation can improve efficiencies in claims processing, reduce the cost to collect, improve the patient experience, and beyond. And while revenue cycle staff can better understand systemic problems and deploy efforts to correct the root causes of revenue loss through technology, you can't expect it to be the sole fix to your problems, leaders said at the Exchange.
"Technology isn't always the fix. You can't just slap tech on top of broken processes hoping to fix them," said Chris Johnson, vice president of revenue cycle management for Atrium Health.
Significant time and energy need to be spent streamlining your workflow and mending broken processes before you can bring in new technology and automation, especially if you want it to work.
Don't expect to replace all FTEs with automation
Upskilling or reskilling revenue cycle staff to fill gaps instead of just automating processes is key, leaders say. Automation is great, but leaders said they are finding that it doesn’t necessarily negate the need for that human touch.
With staffing shortages, revenue cycle leaders are looking internally to leverage the potential of their workforce to work across various roles, and that’s not something technology can always achieve.
"We thought we could use tech to replace FTEs, but it actually made the case that we need more staff to touch what automation can't," said Jennifer Johnson, divisional director of utilization management at Advent Health.
By realizing the potential of the existing workforce, organizations can increase retention while also meeting financial goals. Rather than replacing staff with automation in the front, middle, or back end, leaders find it helpful to upskill or reskill to support revenue cycle functions that still work best with a human touch.
Don't let vendors off the hook
Leaders at the event explained that they are constantly approached by vendors promising to fix their problems—before even knowing what their problems are.
Because revenue cycle leaders are constantly bombarded by new solutions and technology, they need to be sure the solution is the right fit.
Some of the leaders at larger health systems said that they now build a test period into their contracts with vendors for new technology. A few of those leaders have had vendors run new technology (at no cost to the health system) for almost a year before an official go-live in order to ensure the solution actually works for them.
Revenue cycles are robust and complex, so making sure automation and technology works efficiently across the continuum is key.
"For physicians, our biggest concern is time. If new technology is slowing us down or adding more work, we aren't going to be on board," said Trey La Charite, MD, medical director of CDI and coding, at UT Medical Center. Without ample support from those middle revenue cycle teams, automation won’t be successful no matter how innovative it is.
Ensuring organizations have time to test technology, confirming it can work across all revenue cycle teams, and making sure you see positive results—all before an official go-live—is what has guaranteed an ROI for these leaders.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
Health systems are not the only entities now being held accountable for upholding price transparency.
The OIG recently announced it will be assessing CMS' monitoring and enforcement of the hospital price transparency rule. This audit, the OIG says, is expected to be released next year.
"We will review the controls in place at CMS and statistically sample hospitals to determine whether CMS' controls are sufficient to ensure that hospital pricing information is readily available to patients as required by federal law," said the OIG.
The OIG will also evaluate the extent to which CMS enforces the rule. CMS previously said hospitals in noncompliance with one or more of the rule's requirements may receive a written warning notice, a request for a corrective action plan, and civil monetary penalties (CMP).
The clock started in January of 2021 when the first of three different rules and laws that dictate price transparency went into effect.
Adherence to the regulation has been off to a slow start as many organizations site administrative burdens and revenue cycle workforce shortages as the cause to slow adoption.
"If hospitals are not in compliance with CMS' rule for listing their charges, we will contact the hospitals to determine the reason for noncompliance and determine whether CMS identified the noncompliance and imposed consequences on the hospitals," said the OIG on its upcoming audit.
When first shoring up price transparency processes, there are two main requirements that organizations need to adhere to immediately, Connie Lockhart, director of strategy and operations at Impact Advisors, previously shared with HealthLeaders.
"Revenue cycle leaders need to first make sure they are following CMS' guidelines to complete a comprehensive, machine-readable file of all services and items," she says.
"Ensure all requirements are met—like how a separate file must be posted for each hospital. And be cognizant of multiple hospitals operating under a single hospital license with different sets of standard charges."
Also, ensure that list is posted on a publicly available website.
Once completed, make sure to post a display in a publicly available website of 300 shoppable services in a consumer-friendly format. This should include the 70 CMS-specified, shoppable services, Lockhart says. Revenue cycle leaders should also establish a cadence to ensure both displays are updated annually, Lockhart says.
A handful of medical associations and groups show support to the Texas Medical Association (TMA), again.
The TMA recently filed another lawsuit stating that the surprise billing final rule independent dispute resolution (IDR) process still fails to comply with the No Surprises Act statutory text.
The new TMA suit is filed in the same Texas Federal Court that ruled in favor of the TMA earlier this year. That ruling vacated parts of the IDR process published in the surprise billing interim final rule issued last September.
The departments of Health and Human Services, Labor, and the Treasury officially revised the IDR process in August. At the time, CMS referenced the court decision, saying it will "remove the provisions that the District Court vacated." Now IDR entities may weigh qualified payment amounts and other factors equally in making their decisions.
This is still unjust, the TMA says, and major medical associations are showing their support for the TMA's newest filing.
The American College of Emergency Physicians (ACEP), American College of Radiology® (ACR), and American Society of Anesthesiologists (ASA) filed a joint amicus brief with the Texas court in support of the TMA. The American Hospital Association (AHA) and American Medical Association (AMA) also joined forces and filed a similar amicus brief.
According to the ACEP, ACR, and ASA, the groups will monitor the newest TMA suit and stand ready to challenge the final rule in the Northern District of Illinois if necessary.
"Many practices, reeling from COVID-19's economic impact, cannot withstand this insurer multi-edged profit grab and may be dropped from networks. These insurer restrictions impact all care (not just out-of-network care), including cancer screenings, which plummeted during the pandemic and may yet lead to more cancer deaths," the ACEP, ACR, and ASA said in a press release.
The AHA and AMA declared a similar mindset.
"Based on their own apparent policy preferences, the Departments continue to add atextual requirements to Congress' simple framework," AHA and AMA wrote.
"Indeed, six months after this Court definitively interpreted the No Surprises Act, the Departments promulgated a Final Rule with numerous extra-statutory requirements that will interfere with a balanced consideration of Congress' mandated factors and put a thumb on the scale in favor of the QPA," the AHA and AMA said in its brief to the court.
"The severe rate cuts enabled by the Departments' insurer-friendly regulations threaten the viability of physician practices and the scope of medical services nationwide. Ultimately, the victims will be the patients who lose ready access to care."
The Texas case again solely impacts the IDR process to determine provider reimbursement for out-of-network care. The suit does not impact No Surprises Act patient protections or raise patient out-of-pocket costs.
The AHA and AMA strongly believe that no patient should fear receiving a surprise medical bill and that patients should be kept out of the middle of any billing disputes between providers and commercial health insurance companies.
The groups say they want to see the law’s core patient protections move forward and seek only to bring the regulations in line with the law.
While the chilly October rain falls over Boston, prominent revenue cycle leaders are cozying up inside the Boston Park Plaza hotel to discuss revenue cycle technology optimization.
Automation and technology are obviously top of mind for the executives attending this week's HealthLeaders RevTech Exchange. As regulatory burdens and workforce shortages put strains on their revenue cycles, leaders agree technology is where they need to be investing.
"When we think of revenue cycle technology, we need to think about technology in ways that don't just push more work onto other staff, but ways to really automate and streamline our processes," Michael Finley, director of revenue cycle at Bellin health, said during the event kickoff.
Finley is just one of the many revenue cycle executives attending this event designed to bring leaders together to discuss revenue cycle technology strategy.
In a poll conducted by HealthLeaders at the beginning of the event, 47% of the group said their revenue cycle operations are fully automated, while 83% said revenue cycle technology transformation is an absolute and immediate need for their organization.
Today's event included a dynamic workshop led by CIO and digital health futurist Ed Marx where he discussed how revenue cycle teams are now looked upon to raise patient satisfaction while also increasing efficiency.
Discussion sessions were also held that focused on robust conversations about automating front-end processes, including prior authorizations and good-faith estimates, and using technology to help relieve staffing shortages.
Stay-tuned for more coverage of this event which will include “ideas presentations” from prominent leaders such as Lynn Ansely, vice president of revenue cycle management at the Moffitt Cancer Center, and Jennifer Johnson, executive director of utilization management at AdventHealth.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
As more hospitals face financial uncertainty, revenue cycle leaders need to work to help improve the bottom line, and sometimes that means reworking your revenue cycle.
Over the past several years, many health systems have run into underperforming metrics, insufficient workflows, and undefined roles within the revenue cycle.
Hawaii Health Systems Corporation (HHSC) Kauai Region was running into these same challenges, so it began tackling these issues in 2019 by focusing its efforts on creating a clinically driven revenue cycle, meaning Kauai Region aligned its clinical and financial information with a twofold goal in mind: improve clinical outcomes and reduce costs.
"We had become burdened by our EHR system because we didn't understand it. But now, we're not. When we got our system to work more efficiently for us, it freed up staff time so we could focus on other things like bringing self-pay in-house," said Christine Asato, regional CFO for HHSC Kauai Region.
Putting the focus on process and training, along with the engagement of an operational revenue cycle architect, helped HHSC Kauai Region increase its average daily revenue by 7%, Asato said.
Staff were not only able to track performances through a clinical lens, but also follow patient journeys within its facilities. This helped HHSC Kauai Region in its effort to reduce time spent on manual charge captures.
Pictured: Christine Asato is the Regional CFO of HHSC Kauai Region. Photo courtesy of HHSC Kauai Region.
"That's the beauty of having a clinically driven revenue cycle. It allows a hospital to operate more efficiently and effectively and really have the system work for you—instead of the other way around," said Asato.
Through this revenue cycle optimization, Asato says there are two main reasons for the increase in its revenue: better charge capture from its EHR system and an increase in swing bed utilization.
So how can other healthcare organizations and revenue cycle leaders do the same? Asato said HHSC Kauai Region was able to pull this off with help from the third-party vendor Cerner.
After implementing an EHR platform that supported its clinical, financial, and operational needs, HHSC Kauai Region was able to drop its gross accounts receivable days by 8.8%, decrease accounts receivable greater than 90 days by 12.6%, and increase payments by 61.7%.
To fully benefit from revenue cycle optimization, it's important to understand the revenue cycle puzzle pieces and how those pieces connect to each other and the bigger picture, Asato said.
"Patient financial services is responsible for getting the claim out the door and the payment in our bank; registration is responsible for getting accurate demographic information from the patient; coding is responsible for assigning codes based on the documentation provided in the chart; and our clinicians and providers are responsible for making sure all services performed are documented in the chart in a complete and timely manner. When all these moving pieces are working as designed, it becomes the glue that holds us all together," Asato said.
Because of the success in creating a clinically driven revenue cycle, Asato had much to say when asked what tips she had for other revenue cycle leaders looking to optimize their revenue cycle in the same way:
Asato: I think the biggest tip that I can give is to, first, engage with your revenue cycle architecture team because they understand the system and can help address workflows. Unless you understand the design and flow of the EHR you are implementing, you cannot begin to optimize your workflow or even capture the revenue in real time.
Looking back on our experience at Kauai Region, I share this mantra: If you document it, the charges will come. What was instrumental in the growth of our charge capture wasn't that our teams weren't taking great care of our patients; it's that we weren't able to bill for every service performed.
As revenue cycle leaders, it's important to think about these projects, not from a financial standpoint, but from a clinical documentation standpoint using the EHR as a tool and not a check the box exercise. You need to tell the story of the care provided to the patient that can be shared across their continuum of care in a meaningful and timely manner. When you place your emphasis on documentation, the charges will come. That's how the system is built.
Finally, I think the beauty of having a clinically driven revenue cycle is that it allows a hospital to operate more efficiently and effectively. But if you don't get it right, you become enslaved to your system, and end up spending valuable time and resources cleaning up the mess.
If you're in the clean-up phase it's easy to blame the system, but this is the time to take a break and really dive into your workflows to figure out how to get the system to work for you. It all starts with the order and flow of capturing information and when done properly–and in the right sequence–you will create a win/win in the clinical and financial aspects of the revenue cycle.
A new report outlines the healthcare industry's progress to date on price transparency compliance.
A recent price transparency impact report,conducted by Turquoise Health, highlights a positive trend in adherence to the regulation.
According to the report, 76% of hospitals have posted a machine-readable file (MRF), 65% have posted an MRF with negotiated rates, and 63% have posted an MRF with cash rates.
Major health systems such as the Mayo Clinic, Advocate Aurora Health, and Prime Healthcare, have posted 5-star MRFs, the highest possible score, according to the Turquoise Health price transparency scorecard.
On the payer data side, 80 carriers have published rates. This includes BlueCross BlueShield, United, Cigna, Aetna, and Humana, the report said.
"We expect the initial phase of price transparency adoption to take five years," says Turquoise Health CEO, Chris Severn.
The clock started in January of 2021 when the first of three different rules and laws that dictate price transparency went into effect. The price transparency rule requires health systems to publicly post the costs of their items and services online.
The posted prices must include standard charges for all items and services for all payers and health plans and a standard charges list or a price estimator tool for the 300 most common services.
Adherence to the regulation has been off to a slow start as many organizations site administrative burdens and revenue cycle workforce shortages as the cause to slow adoption.
It seems though, that organizations are finally catching up.
"After seven quarters of transparency, progress is evident. 65% of hospitals have published robust negotiated rates. Additionally, 80 carriers have also published rates, representing over the majority covered lives in the United States," Severn said in a press release.
This newest report shows a step in the right direction as many recent studies have shed light on the large lack of adherence.
For example, as recently as August, the Semi-Annual Hospital Price Transparency Compliance Report found that hospitals as a whole had made little progress on complying with the price transparency rule. At that time, the report revealed that just 16% of hospitals were adhering to all necessary requirements for providing pricing data for patients.
Revenue cycle leaders should ensure their organizations are in compliance with all provisions of the hospital price transparency final rule. Adding price transparency to internal audit plans and making sure public-facing price information is current will help your departments and organization avoid repercussions.
The American Medical Association (AMA) says the 2023 CPT code updates emphasize its efforts to reduce administrative tasks.
The AMA released the calendar year 2023 CPT code set, which builds on the AMA's efforts to reduce administrative tasks in medicine, according to a recent press release.
The CPT code update contains 393 changes, including 225 new codes, 75 deletions, and 93 revisions.
Modifications to evaluation and management (E/M) codes make up the majority of the changes, but the update also includes new codes for virtual reality therapy, procedural dissociation services, and abdominal hernia repair procedures. These codes become effective on January 1, 2023.
In its press release article debuting the new code set, the AMA explains the code updates build on its efforts to reduce administrative tasks in medicine—a driver of burnout and a central pillar of its Recovery Plan for America's Physicians.
Based on the 2021 revisions made to the E/M office visit CPT codes, the AMA says the new modifications make coding and documentation easier and more flexible, freeing physicians and other staff from time-wasting administrative tasks that are irrelevant to providing high-quality care to patients.
As background, those 2021 updates, which were approved by both the AMA and CMS, made it so E/M codes no longer factor history and exam elements into code level selection. Instead, code selection is now solely based on either medical decision-making or time.
The new modifications to the E/M codes for 2023 extend to inpatient and observation care services, consultations, emergency department services, nursing facility services, home and residence services, and prolonged services, the AMA said.
"The process for coding and documenting almost all E/M services is now simpler and more flexible," AMA President Jack Resneck Jr, said in the press release.
"We want to ensure that physicians and other users get the full benefit of the administrative relief from the E/M code revisions. The AMA is helping physicians and healthcare organizations prepare now for the E/M coding changes and offers authoritative resources to anticipate the operational, infrastructural, and administrative workflow adjustments that will result from the pending transition," Resneck said.
The coding department is one of the most critical parts of the revenue cycle. 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.
Staying abreast of these regulatory coding updates is important for revenue cycle leaders as coding—and its completeness and accuracy—has a profound impact on an organization's bottom line.
So, what if your back-end revenue cycle staff are finding errors in their billing? Healthcare attorneys told Part B news it isn't the end of the world if you take the right steps in response.
Revenue cycle leaders shouldn’t be surprised if errors are found. It's difficult to implement new coding and billing rules under ideal conditions, and most organizations in 2020 had to get up to speed on telehealth services during a public health emergency and keep track of a steady stream of new and revised coding and billing rules.
According to Part B News, there are six steps that revenue cycle leaders should take when your teams begin to review telehealth claims:
Read the data brief. "The OIG data brief is a useful compliance roadmap for providers, and one that should inspire both providers and telemedicine companies to take a closer look at internal coding, billing, auditing, and monitoring practices, which serve as important checks and balances in any health care organization," says Amy Lerman, member of the firm with Epstein Becker Green in Washington, D.C. For example, the brief includes seven program integrity measures that the OIG created for telehealth services.
Increase your red flag knowledge base. You should also use HHS' list of common telehealth billing mistakes when you review claims. Mistakes include using or reporting:
The wrong codes. The wrong code can delay payments or cause improper payments. For example, confusion about when to report a telephone code versus an office/outpatient visit code may have caused improper coding.
The wrong documentation. In addition to meeting the documentation requirements for the service, your practice must document whether the patient gave you verbal or written consent to conduct a virtual appointment, according to the HHS. In addition, the provider must clearly document whether the connection was audio and visual or audio-only.
The wrong time. A common mistake made by organizations is the billing of time a patient spent with clinical staff, the HHS report says. Staff should only bill for the time spent with the patient.
Probe if you find a problem. You don't need to drop everything and start a full-scale review of every claim if you find one error, but ignoring the error is not an option. You should find out what caused the mistake, figure out its scope and act on your findings, such as returning an overpayment.
Conduct a thorough analysis into what caused the error. "Secondarily, the organization should conduct a root cause analysis to determine whether any bigger picture solutions need to be implemented," Lerman says. Those solutions could include better training, improving the practice’s coding and billing resources, and correcting behavior that could be fraudulent.
Bring in outside help. If you discover a serious issue such as dozens of incorrect claims or signs that point to fraud, don't try to tackle the problem on your own. "This is one of those instances in which we recommend practices work with their counsel," says Sara Shanti, partner with Sheppard Mullin in Chicago. Fraud, waste, or abuse "may not be the only issue, so it is important to investigate," Shanti says.
Document everything you do. The enduring maxim, if it isn't documented, it isn't done, applies to compliance efforts as well as providers' work. A written record of the steps your revenue cycle took will help build up a compliance plan, prevent mistakes in the future, and, if the worst happens and your health system is investigated, it will show the government that you tried to do the right thing.
A recent survey says prior authorization requirements and other regulatory burdens are weighing heavy on providers.
The recent Medical Group Management Association's (MGMA) 2022 Annual Regulatory Burden Report says 89% of respondents reported that the overall regulatory burden on their organization has increased over the past 12 months.
On top of this, prior authorization requirements ranked as the top burden for providers in the survey, with requirements stemming from the No Surprises Act and Medicare's Quality Payment Program coming in second and third.
According to the survey, 97% of respondents agreed that a reduction in regulatory burden would allow their practice to reallocate resources toward patient care.
"Medical groups continue to face growing challenges with prior authorization, including delays in prior authorization decisions, inconsistent payer payment policies, and processing prior authorizations for routinely approved items and services," the MGMA survey said.
Because of reasons such as these, 89% of respondents stated that their practice had to hire or redistribute staff to work on prior authorizations due to the increase in requests.
"The increase in prior authorization requirements year after year is simply unsustainable," Anders Gilberg, SVP of Government Affairs at MGMA, said in a statement.
"Practices are being forced to divert resources away from delivering care to contend with these onerous and ever-changing requirements. It is time that Congress acts to put commonsense guardrails around prior authorization programs. We urge the expedient passage of the Improving Seniors' Timely Access to Care Act before the end of this year," he said.
The survey by the MGMA gathered responses from over 500 medical group practices. The group says its Government Affairs team utilizes this data to inform Congress about the obstacles faced by medical practices to delivering high-quality patient care.
Missing hospital prices in coverage data shows that hospitals are still violating the price transparency rule.
Once again, research finds that not all hospitals are posting their complete price lists as required by federal price transparency rules, according to the latest analysis by PatientRightsAdvocate.org.
According to the report, newly released health insurance company data files show that there are large hospital systems that are still omitting prices from their required disclosures, which is a violation of the requirement.
The group states that by cross-referencing 20 price disclosures made by hospitals and health insurers in accordance with these two rules, it discovered several instances in which prices were omitted from the hospital files but appeared in the insurance company files.
"The discrepancies indicate that some large hospitals are not posting their complete price lists as required by the hospital price transparency rule," the report said.
The examples of missing hospital pricing data uncovered include prices negotiated with insurers such as Blue Cross Blue Shield, United Healthcare, and Cigna, the report noted.
Since going into effect last year, the price transparency requirement demands hospitals disclose gross charges online through a comprehensive machine-readable file with all items and services they provide, as well as through a display of shoppable services in a consumer-friendly format.
While this study highlights larger systems that are not complying, an earlier study by Northwestern University's Feinberg School of Medicine found a correlation between smaller hospitals with fewer beds with a lack of adherence to the price transparency mandate.
In August, the Semi-Annual Hospital Price Transparency Compliance Report found that hospitals as a whole had made little progress on complying with the price transparency rule. At that time, the report revealed that just 16% of hospitals were adhering to the necessary requirements for providing pricing data for patients.
When first shoring up price transparency processes, there are two main requirements that organizations need to adhere to immediately, Connie Lockhart, director of strategy and operations at Impact Advisors, previously shared with HealthLeaders.
"Revenue cycle leaders need to first make sure they are following CMS' guidelines to complete a comprehensive, machine-readable file of all services and items," she says. "Ensure all requirements are met—like how a separate file must be posted for each hospital. And be cognizant of multiple hospitals operating under a single hospital license with different sets of standard charges."
Also, ensure that list is posted on a publicly available website.
Once completed, make sure to post a display in a publicly available website of 300 shoppable services in a consumer-friendly format. This should include the 70 CMS-specified, shoppable services, Lockhart says. Revenue cycle leaders should also establish a cadence to ensure both displays are updated annually, Lockhart says.