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.
According to the report, CMS should recover overpayments of $1 billion resulting from incorrectly assigning severe malnutrition diagnosis codes to inpatient hospital claims, ensure that hospitals bill appropriately moving forward, and conduct targeted reviews of claims at the highest severity level that are vulnerable to upcoding.
In a previous audit, the OIG found that hospitals incorrectly billed Medicare for severe malnutrition diagnosis codes for 173 of the 200 claims that we reviewed.
In that audit, the OIG found that hospitals used severe malnutrition diagnosis codes when they should have used codes for other forms of malnutrition or no malnutrition diagnosis code at all, resulting in net overpayments of $914,128 for the claims in its sample, the OIG said.
"On the basis of our sample results, we estimated that hospitals received overpayments of $1 billion for incorrect severe malnutrition diagnosis codes for fiscal years 2016 and 2017," the report said.
At the time, the OIG said it also found that hospitals are increasingly billing for inpatient stays at the highest severity level, which is the most expensive. The number of stays at the highest severity level increased almost 20 percent from fiscal year 2014 through fiscal year 2019, ultimately accounting for nearly half of all Medicare spending on inpatient hospital stays, the report said.
To remedy the situations the OIG gave CMS a lengthy list of suggestions, and while the OIG says CMS has started to take initial steps toward implementing the recommendations, there is more work to be done; thus, landing this issue on the 2022 list.
"In response to our recommendation that CMS conduct targeted reviews of Medicare Severity Diagnosis Related Groups and stays that are vulnerable to upcoding, as well as the hospitals that frequently bill them, CMS did not concur but acknowledged that there is more work to be done to determine conclusively which changes in billing are attributable to upcoding," the OIG said.
Further oversight and recovery audit contractor reviews, which are already being conducted, are essential to ensuring that Medicare dollars are spent appropriately, the report noted.
Strong CDI and physician collaboration directly contributes to the overall health of an organization's revenue cycle.
With the growth of automation, data availability, and tracking, it is increasingly important for the middle revenue cycle to become a priority for healthcare organizations, and department collaboration is the key to success.
That's why Kearstin Jorgenson, operations director of physician advisor services, and Dr. Kory Anderson, medical director of physician advisor services, CDI, and quality, at Intermountain Healthcare worked to streamline their middle revenue cycle by bringing their physician and CDI teams together.
Here are three tips they have for other revenue cycle leaders looking to improve team collaboration.
Center key performance indicators (KPI) on quality metrics
Dr. Anderson and Jorgenson have talked to numerous facilities around the country, and they see many aligning under a finance focus. Finance can be the loudest message sometimes, but what needs to resound is quality, they said.
Intermountain Healthcare focused on quality metrics that were directly impacted by clinical documentation, physician engagement, and education.
"We used to struggle to get an audience," Dr. Anderson said. "Now people are coming to us to talk about strategies and what they could do to improve those metrics."
Bring teams together in a way that still enables them to do their best work
For Intermountain Healthcare, the CDI nurses continue to focus on trends and identify what the team needs to learn. They collaborate with the physicians, and then the physicians go out and build relationships, look for common and shared understanding, and deliver educational presentations.
Bring education work in-house when possible
Intermountain Healthcare used to contract education out to vendors. Now the team does in-house training whenever possible.
Dr. Anderson and Jorgenson say they're getting better engagement with providers because educational sessions are happening between colleagues.
The person leading the session and those who attend see and work with each other in the hospital every day. This allows for more natural accountability and continuous improvements and adjustments because conversations can happen on the job and in the moment, they said.
Follow-through is also greater with in-house education. Intermountain Healthcare has set up quarterly meetings to connect on what’s going well, what isn’t going well, and how to close the gaps.
Reported housing instability is linked to higher hospital admission rates for mental disorders, longer inpatient stays, and substantial healthcare costs, a recent study found.
Social determinants of health (SDOH) are social factors, such as homelessness, illiteracy, a history of childhood trauma, and joblessness or underemployment, that can affect a person’s health.
With increasing attention on population health and quality initiatives, organizations have turned their focus on SDOH and how capturing those ICD-10-CM codes impacts their patient population and their success in caring for that population.
As your middle revenue cycle works to report SDOH more accurately, a recent study is now showing what can be learned from reporting these diagnosis codes appropriately.
A recent study published in JAMA Network Open found that reported housing instability is linked to higher hospital admission rates for mental disorders, longer inpatient stays, and substantial healthcare costs.
Researchers at the University of Michigan Institute for Healthcare Policy and Innovation reviewed more than 87 million hospital records for patients 18 to 99 years old using the 2017 to 2019 national inpatient sample. The researchers then screened those records for the ICD-10-CM codes related to housing instability.
The researchers then analyzed the records to determine associations between coded housing instability and reason for inpatient hospitalization, length of stay, and cost of admission.
Researchers found that housing instability was associated with higher rates of admission for mental, behavioral, and neurodevelopmental disorders. In addition, housing instability was significantly associated with longer hospital stays (6.7 versus 4.8 days) and high medical costs.
Between 2017 and 2019, inpatient hospitalization costs for patients with coded housing instability was $9.3 billion. These findings highlight the importance of improving tracking of housing status in healthcare and taking steps to better address the needs of patients experiencing homelessness.
Lifepoint Health's vice president of revenue cycle operations chats about trends the health system is watching for 2023.
Hospitals and health systems have been struggling financially as they try to navigate rising expenses.
Challenges like this mean organizations are going to finish out the year in the red, according to recent reports from Kaufman Hall.
As organizations plan to tighten their belts in 2023, revenue cycle leaders are feeling the pressure of cost cutting, regulatory burdens, and staffing shortages.
HealthLeaders recently chatted with Tina Barsallo, vice president of revenue cycle operations at Lifepoint Health, to get a better idea of the revenue cycle trends the health system is following for 2023 and how it navigated challenges in 2022.
HealthLeaders: How has the financial strain on hospitals affected your revenue cycle in 2022? Did budget cuts or restraints have you adjusting any workflows or processes?
Tina Barsallo: Reductions and the strains on ability to hire have created the need for additional automation around patient access and patient self-scheduling here at Lifepoint.
Also, manual claim reviews and delays in authorizations with payers have caused increased denials, appeal delays, and untimely payment. As payers allow, additional Joint Operations Committee meetings have been established to work through delays and various processing backlogs.
Staffing challenges have also created the need for modified workflows on low balance insurance follow up and need to outsource/offshore certain customer service and follow up activities.
HealthLeaders: What was your biggest obstacle in the revenue cycle for 2022 and how did you overcome it?
Barsallo: Staffing and recruitment. Changes in payer policies and behaviors post-pandemic drove the need to establish new approaches, modify workflows, and additional payer meetings without additional resources at best.
Pictured: Tina Barsallo, vice president of revenue cycle operations at Lifepoint Health. Photo courtesy of LinkedIn.
HealthLeaders: What trends do you see coming for revenue cycle leaders in 2023?
Barsallo: In 2023, we anticipate we will continue to see the same challenges, such as staffing challenges, regulatory changes (like pricing transparency and the No Surprises Act), payer policy changes with limited notice, higher volume of post-pay reviews, and denials and underpayments as a result.
On a positive note, CMS has delayed enforcement of part of the No Surprises Act which will give us the much-needed time to work on ways to automate the good faith estimates, an essential part of the act.
HealthLeaders: On that note, what regulatory burdens are you watching the closest for 2023?
Barsallo: Definitely the No Surprises Act. We want to create ways to better automate and communicate the good faith estimates with co-providers, patients, and payers.
HealthLeaders: What is one goal you have for your revenue cycle in 2023?
Barsallo: In 2023 we want to implement patient experience technology to help minimize resource constraints and improve performance (reduced wait times, speed to schedule, etc.) by increasing automation and patient self service capabilities. We also want to offer scheduling ‘as a service’ at our facilities.
Enforcement for certain good faith estimate (GFE) provisions are being delayed.
CMS recently gave revenue cycle leaders an extension of its enforcement discretion on the convening provider requirements that are part of the GFE in its newest FAQ.
Under the law, healthcare organizations need to give patients who don't have certain types of healthcare coverage—or those who are paying out of pocket—an estimate of their bill before services are provided.
Not only do these GFEs need to be created, but they also need to be created quickly as patients have the right to receive a GFE for the total expected cost of items and services as soon as they schedule an appointment (the items can include costs of tests, drugs, equipment, hospital fees, and more).
The GFEs also need to be accurate since patients can dispute final medical bills if the charges are at least $400 more than what was presented on the GFE.
On top of all of this, the rule also includes a "convening provider" requirement.
This means GFEs need to cover not only the provider’s own services, but those of downstream providers expected to be needed to complete treatment.
This specific requirement has been an area of contention for hospitals and medical groups. In fact, the MGMA recently pleaded with CMS to extend the enforcement discretion for the convening provider/facility and co-provider/facility provisions for GFEs.
At the time the MGMA said enforcement discretion should continue until appropriate standards have been developed, tested, and implemented by group practices.
According to the recently published new guidance, CMS said HHS is extending enforcement discretion, pending future rulemaking, for situations where GFEs for uninsured or self-pay individuals do not include expected charges from coproviders or co-facilities until further notice.
Enforcement of this part of the No Surprises Act requirement was expected to start January 1, 2023.
WEDI recently applauded this guidance and Charles Stellar, WEDI president and CEO, went on to say that "the industry continues to make progress in developing data interchange standards to support the requirements of the No Surprises Act. We commend HHS for extending the enforcement discretion period and averting significant administrative burdens on providers. The HHS action today grants the time necessary to develop cost efficient solutions and implement supporting regulations."
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 November, including the OPPS and physician fee schedule final rules.
Here are the five updates you need to know.
Medicare providers did not always comply with federal requirements when billing for advance care planning.
The OIG published a review regarding whether Medicare providers who received payments for advance care planning (ACP) services in an office setting complied with federal requirements.
The OIG found that 466 of the 691 ACP services did not comply with federal requirements. Issues included providers claiming that they did not know that the time for ACP services had to be distinguished between time spent discussing ACP and time spent on concurrent services. Some providers said they were unaware there was a time requirement.
The OIG said that, based on this sample, it estimates that Medicare providers received approximately $42.3 million in payments for ACP services that did not comply with federal requirements.
The OIG also noted that it found some claims where 15 or more ACP services were received during the 12-month audit period, and while that did not reflect noncompliance, it did not align with CMS guidance in an FAQ suggesting that ACP services billed multiple times for a beneficiary should include a documented change in the beneficiary’s health status, end-of-life care wishes, or both.
The OIG recommends CMS educate providers on documentation and time requirements for ACP services, instruct the MACs to recoup the money paid in error for claims in the sample, and instruct the MACs to notify providers so they can identify, report, and return similar overpayments.
The OIG also recommends CMS establish requirements that address when it is appropriate to provide multiple ACP services for a single beneficiary and how these services should be documented to support the need for multiple ACP services. CMS concurred with all but the fourth recommendation.
Medicare improperly paid physicians for co-surgery and assistant-at-surgery services that were billed without the appropriate payment modifiers.
The OIG published another noteworthy review in November, this one focused on whether Part B payments to physicians for potential co-surgery procedures complied with federal requirements.
The OIG found that 69 of the 100 statistically sampled services did not comply with requirements. This included 49 services incorrectly billed without the co-surgery modifier, 14 incorrectly billed without an assistant-at-surgery modifier, and six that were incorrectly billed as duplicate services.
The OIG also reviewed 127 corresponding services and found that 62 of those did not comply with federal requirements, as 33 were incorrectly billed without the co-surgery modifier, 16 were incorrectly billed without an assistant-at-surgery modifier, and 13 were incorrectly billed as duplicate services. The OIG determined that these errors resulted in $56,016 in overpayments.
The OIG recommends CMS recover the portion of the $56,016 in Part B overpayments within the claim reopening period, instruct Medicare providers to identify, return, and report any similar overpayments, strengthen its system control to detect and prevent improper payments for these types of services, and update Medicare requirements and corresponding educational material to improve providers’ understanding of the Part B billing requirements for co-surgery procedures.
CMS concurred with these recommendations.
Medicare began its enrollment of rural emergency hospitals.
CMS published a transmittal regarding the addition of information about rural emergency hospitals (REH) enrollment applications to the manual.
This information walks through the process for a critical-access hospital or rural hospital wishing to convert to an REH and provides instructions for the contractors on processing these enrollment applications. The transmittal was originally published internally on September 15, but it is no longer sensitive information and is now posted for the public.
The 2023 Medicare physician fee schedule final rule was released.
CMS published the 2023 Medicare physician fee schedule final rule. The rule finalized a decrease in the conversion factor down from $34.61 in 2022 to $33.06 in 2023 (two cents less than the $33.08 listed in the proposed rule). Other policies finalized in the rule include:
Adopting coding/documentation changes for E/M visits (including hospital inpatient, observation, emergency department, and more) that align with changes made by the AMA CPT Editorial Panel for January 1, 2023. This includes eliminated use of history and exam to determine code level, revised interpretive guidelines for levels of medical decision-making, and the choice of medical decision-making or time in determining code level.
Delaying the split-shared visits policy until 2024. This policy will change the definition of the substantive portion as more than half the total time.
Extending the time that telehealth services are temporarily included on the telehealth services list during the PHE but are not included on a Category I, II, or III basis for 151 days following the end of the PHE. Providers should continue to report telehealth services with modifier 95 during the PHE, but audio-only services should be reported with modifier 93 effective January 1, 2023.
Making an exception to direct supervision requirements under “incident to” regulations allowing behavioral health services provided under general supervision of a physician or non-physician practitioner (NPP) when the services or supplies are provided by auxiliary personnel incident to the services of a physician or NPP.
Codifying the reporting of modifier -JW for reporting wastage for all separately payable drugs with wastage from single use vials or single use packages effective January 1, 2023, and the reporting of modifier -JZ for reporting single use vials or packages with no discarded amount effective July 1, 2023, with editing beginning October 1, 2023. Other issues were clarified in commentary.
Codifying changes to coverage of certain dental care inextricably linked to and substantially related and integral to the clinical success of covered medical services.
The rule is effective January 1, 2023.
The outpatient prospective payment system (OPPS) final rule was also released.
CMS published the 2023 OPPS final rule. The rule finalizes updates to both OPPS and ambulatory surgical center (ASC) PPS payment rates by 3.8% for 2023, significantly higher than the proposed 2.7% increase in payment rates.
Policies finalized in the rule include:
340B payment rate updates.
Removing 11 services from the inpatient-only list, adding eight services to the inpatient-only list, and adding four services to the ASC covered procedures list.
Continuing coverage for behavioral health services furnished remotely by hospital staff to beneficiaries in their homes beyond the end of the public health emergency (PHE) as long as the beneficiary receives an in-person service within six months prior to the first remote service and once every 12 months following that.
Adding facet joint injections and nerve destruction as an additional service that would require prior authorization, effective July 1, 2023, rather than the proposed date of March.
Approving four of the eight applications for device pass-through payments for CY 2023.
Finalizing changes to the supervision requirements for diagnostic services to allow non-physician practitioners to supervise diagnostic services within their scope of practice, similar to services provided under the physician fee schedule.
CMS is implementing a requirement from the Consolidated Appropriations Act of 2021 to establish REH as a new provider type. Critical access hospitals and certain rural hospitals may choose to convert to an REH and would be allowed to provide emergency department services, observation care, and certain outpatient medical and health services.
