While some organizations already have systems in place to adhere to price transparency requirements, opportunities still exist to adjust outdated revenue cycle processes.
The No Surprises Act, which became effective January 1, requires hospitals to post the prices for their most common procedures as well as offer a patient-friendly tool to help shop for 300 common services.
Unfortunately, most organizations are behind in adhering to this requirement—still.
Earlier this year,JAMA published a study that concluded that out of the 5,239 hospital websites evaluated, roughly 51% of hospitals did not adhere to either price transparency requirement.
Almost 14% of hospitals studied had a machine-readable file but no shoppable display, while 30% of hospitals had a shoppable display but not a machine-readable file, according to the study. It also found less than 6% of hospitals were compliant with both components of the mandate.
Of the hospitals studied, 5.1% were in total noncompliance as they did not post any standard charges file, and 51.3% failed compliance because the majority of their pricing data was missing or incomplete.
While some organizations now have systems in place to help them adhere to the new rules, opportunities still exist to revisit outdated revenue cycle processes to better comply with these regulations.
Connie Lockhart, director of strategy and operations at Impact Advisors, discussed with Healthleaders six key strategies that revenue cycle leaders can use to increase price transparency, mitigate the risk of surprise billing, and support efforts to improve the patient experience through enhanced revenue cycle processes.
Before diving into the six key strategies, when first shoring up price transparency processes (and as mentioned in the studies above), there are two main requirements that organizations need to adhere to immediately.
"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.
Once the basics of price transparency are in place, revenue cycle leaders can then move to streamlining other areas of the requirement. Here are six key strategies Lockhart suggests.
Shore up your scheduling
Improve the patient experience with better access to scheduling appointments and verifying patient eligibility, Lockhart says.
For eligible self-pay patients, revenue cycle leaders should ensure timelines are in place for governance of the No Surprises Act. It is the provider’s responsibility to verify if the patient is self-pay, so looping in front-end revenue cycle staff to address this task is a must.
For example, if a patient schedules more than ten business days in advance of a service, an organization has three days to issue a good faith estimate. If a patient schedules three days out, staff only has one day to issue the estimate.
Refine those good faith estimates
Patients are consumers, Lockhart says, so it’s important to establish expectations regarding the process for collecting out of pocket expenses. A lot goes into good faith estimate requirements, so it's essential for revenue cycle leaders to stay up to date on those intricacies.
For example, for services provided in 2022, patients can dispute medical bills that are $400 or higher than the good faith estimate that was provided.
For self-pay patients who do not have health insurance or choose not to use it, the good faith estimate is applicable, Lockhart says.
Work on collection communication
Convert the good faith estimate into cash collections to make it a smoother process for both the patient and the organization, Lockhart says.
Implementing scripting, automation of a patient estimator tool, and training for all pre-service/registration staff is key to ensuring timely and consistent communication and collections.
Leverage price transparency to build patient trust
One positive aspect of price transparency for organizations is that it can help build trust by providing patients the cost of service prior to receiving services, Lockhart says.
In order to build this trust with patients, revenue cycle leaders must make sure processes are streamlines and compliant.
"Ensure compliance with pricing transparency and good faith estimates by utilizing the CMS requirements as a baseline to assist in your hospital's review of the hospital price transparency final rule and complete a gap analysis to identify processes/elements that are not aligned with the requirements," Lockhart says.
It's also essential that your chargemaster is easily accessible, and that revenue cycle leaders perform quality checks to include bill audits. Lockhart says this strategy will ensure there is timely, consistent, and accurate communication with the patient regarding the cost of care before both the service and the bill.
Being timely, consistent, and accurate in your price transparency and estimates will build that trust and ensure a positive patient financial experience.
Train staff on point of service collections
Educate and train revenue cycle staff to be able to clearly communicate and explain the good faith estimate to patients, Lockhart advises.
Including scripting and frequently-asked-question handouts will help front end staff better communicate with patients about these prices and bills.
Resolve patient cost share
Revenue cycle leaders can reduce denials and self-pay vendor costs by resolving patient cost share on the front end, Lockhart suggests.
To do so, it's important to implement governance and reporting for point of service collections, and to track and monitor point of service collections (e.g., expected vs. actual payments) on a monthly basis, Lockhart says.
CMS regulations and accompanying surprise billing updates are changing faster than revenue cycle leaders can keep up.
The surprise billing ban was put in place by CMS to protect patients from receiving unforeseen bills for out-of-network and emergency services after receiving treatment. While beneficial for patients, organizations have long shared their distain of the burden this causes for revenue cycle staff.
Revenue cycle leaders need to stay informed of this requirement in order to be compliant and ensure a positive patient financial experience. Review the most recent surprise billing stories from HealthLeaders.
A federal judge denied a New York doctor's lawsuit against the No Surprises Act, dismissing the request for a preliminary injunction and ruling that the law is constitutional.
U.S. District Judge Ann Donnelly rejected surgeon Daniel Haller's injunction to blow the law, which was filed on December 31, 2021, the day before the No Surprises Act took effect.
Haller and his private practice, which performs procedures on patients who are admitted after an emergency department visit, alleged in the complaint that the law is unconstitutional and deprives providers the right to be paid a reasonable payment for their services due to the independent dispute resolution process.
Several aspects of the surprise billing mandate went into effect on January 1 of this year, including federal protections against balance billing, uninsured and self-pay good faith estimate requirements (GFE), continuity of care protections, and provider directory requirements.
While the policies have been beneficial for patients, MGMA says the requirements have created administrative burden for providers as the interim final rules were published with minimal time before implementation.
The workgroup takes aim at the GFE convening provider/facility provision saying it has significant concerns with how this part of the act can be successfully adopted by two providers.
In the letter, WEDI recommends HHS consider an initial phase of the GFE requirement initiated by a patient request, extend the enforcement discretion period, identify standards-based solutions, and phase in the one- and three-day time requirement.
WEDI says these issues should be expeditiously addressed by HHS to ensure successful implementation of the legislative provisions of the act.
"While the No Surprises Act includes much needed consumer protections against catastrophic 'surprise' bills, it also includes challenging data exchange provisions such as the convening provider/facility requirement," stated Charles Stellar, WEDI president and CEO.
Yet 20% of respondents in the Morning Consult survey say they or their family have been charged unexpectedly, with another one in five billed after being treated by an out-of-network provider at an in-network facility.
The bills have been especially costly in some cases, as 22% of respondents say their charges were over $1,000.
Unexpected charges haven't just been an issue after the fact. The survey found about one in four adults delayed or skipped medical care because they were concerned with receiving a surprise bill. Emergency room care suffered the most in this facet, with 14% of respondents saying they did not seek care, while another 14% say they hesitated but ended up receiving care.
As organizations clamber to adhere to price transparency requirements, nearly half of patients have never heard of it.
Healthcare organizations' low compliance with price transparency has been in the spotlight as of late, but an even more concerning statistic comes from the patients: Nearly half (49%) of US consumers have not heard of the price transparency rule at all, according to the recent survey from Cedar.
Conversations around price transparency are commonplace among healthcare professionals, but while 49% of those surveyed have not heard of the price transparency rule, of those who are familiar with it, nearly a quarter (24%) don’t understand it.
Price transparency has yet to move the needle for patients for a variety of reasons, with low compliance and lack of centralized data just to name a few, Cedar told Healthleaders.
But with nearly 90% of consumers having compared the costs of two items while shopping, the survey said, it's clear that organizations need to give patients what they inherently want: the ability to easily price shop and compare costs when seeking healthcare.
As the patient financial experience is top of mind for revenue cycle leaders, now is the time to act. According to the survey, 74% of respondents said they wish their hospital better explained its price transparency compliance to them.
On top of this, 77% of consumers said they would price compare two hospitals prior to receiving care at a hospital if that information was available. 71% of consumers consider price transparency and costs when choosing where they go for medical care, the survey said.
So, what can revenue cycle leaders do to help educate their patients regarding price transparency? Florian Otto, CEO and co-founder at Cedar, spoke exclusively to HealthLeaders on this.
"There are many ways in which revenue cycle leaders can help educate their patients regarding price transparency, including leveraging technology to create a digital front door that prioritizes the consumer experience," Otto said.
"By offering personalized care information, consumers can engage with valuable, user-friendly price transparency data before their visit, and this way providers can ensure there is alignment on payment responsibility before a bill is sent."
The market is anticipated to increase at a compound annual growth rate of 16% from 2022-2032, and by the end of 2032, medical billing outsourcing is expected to reach a valuation of $55.6 billion, the report said.
The report explained that the pandemic has highlighted the significance of adopting proactive actions and establishing a strong, collaborative, and reactive digital healthcare infrastructure.
"As a result, in order to enhance market development, numerous organizations are adopting methods such as digitization and outsourcing of all non-core areas of their operations, such as invoicing and accounting. The rapid move to digital billing is directly related to the growing demand for the medical billing outsourcing market," it said.
This information comes amid reports of high medical billing costs and staffing shortages for the revenue cycle.
According to the study, although most countries use ICD-10, the U.S. has a very different coding process from other countries which is driving up medical billing costs.
On top of high billing costs, workforce shortages have been a major challenge for healthcare leaders and the revenue cycle in particular is in serious need of staffing.
Leaders at Hutchinson Clinic knew they had to keep patient experience in the forefront in order to ensure the success of their revenue cycle.
An important aspect to optimizing the revenue cycle for leaders at Hutchinson Clinic in Hutchinson, Kansas, is the ability to find which methods worked the best for the organization internally, while still working to improve the patient experience.
The clinic has a team of roughly 60 in-house revenue cycle management employees who needed onboarding and training before all processes could be improved. At the same time, Mike Heck, CEO, was adamant that this process didn't disrupt continuity of care for the patients stretched across Hutchinson's large geographic footprint.
"The beauty of working with a partner for onboarding and training is that they're handing all of the heavy lifting behind the scenes, enabling us to focus on patient engagement, provider recruitment, and retention," Heck said. "We've recently seen a positive response from the community as a result."
Being that Hutchinson Clinic is the primary source of care for those in Reno County, it's imperative that patient engagement is at the head.
"We see quality care and patient satisfaction as our number one responsibility," Heck said. "Having a stable revenue cycle management ensures that bills are getting out the door and payments are being made, which frees our team up to focus on other areas."
Echoed Dashun Monk, CFO, "I have peace of mind knowing that our revenue cycle, specifically the coding, accounts receivable, and posting components are happening correctly and in an efficient manner."
As revenue cycle leaders look to streamline processes and leverage technology, one health system did just that by consolidating its electronic health record (EHR) platforms.
Now more than ever, EHR systems play a vital role in running an effective revenue cycle.
As more systems now include revenue cycle management capabilities such as real-time insurance verification, good faith estimate pulls, and more, the integration of EHRs among multi-system hospitals has become a necessity for organizations looking to save money and even reduce the administrative burden of revenue cycle staff.
LCMC Health, a New Orleans-based, six-hospital health system, recently did just that. Now, LCMC Health is saving money by having consolidated all of its hospitals onto a single EHR platform.
Sherri Mills, LCMC Health's chief nursing informatics officer, recently spoke to HealthLeaders contributing writer Scott Mace to explain more.
HIMSS Analytics recently recognized two of LCMC Health's hospitals for reaching Stage 7 of the HIMSS Analytics Electronic Medical Record Adoption Model (EMRAM), the highest validation of EHR adoption bestowed by the HIMSS organization.
The achievement caps the four-year project to migrate LCMC Health's hospitals from six different EHRs, coming at a time when the health system is in a growth and acquisition phase.
"We are relatively young as a hospital system," says Mills. The EHR migration was a key factor, she says, in LCMC Health's efforts to coalesce.
"We know the HIMSS methodology helps organizations take a good look at how they're leveraging technology for patient safety and quality," she says.
The investment in the EHR transition cost the health system tens of millions of dollars, Mills says, but LCMC Health is coming out ahead financially compared to EHR expenses prior to consolidating.
"Through good application rationalization and consolidation, we actually are saving money," she says.
One of its hospitals was actually documenting patient charts on paper before the migration. "They did have a way to do order management [electronically], but documentation was still on paper," Mills says.
Read even more about LCMC’s EHR consolidationhere.
According to the study, researchers used a microlevel accounting of billing and insurance-related costs in different national settings at six provider locations in five nations: Australia, Canada, Germany, the Netherlands, and Singapore. This newest study supplements the prior study measuring the costs in the U.S.
“We found that billing and insurance–related costs for inpatient bills range from a low of $6 in Canada to a high of $215 in the US for an inpatient surgical bill (purchasing power parity adjusted),” the researchers said.
To compare, only Australia had similar billing and insurance-related costs to the U.S. Australia has a mix of publicly and privately funded payers, as well as universal coverage. Billing and insurance-related costs were significantly less in Canada than in the other nations. Germany, Singapore, and the Netherlands had comparable billing and insurance-related costs, the study said.
Interestingly, researchers found one common thread to these higher costs in the U.S. and Australia and it points to one area of the revenue cycle: coding.
According to the study, although most countries use ICD-10, the U.S. has a very different coding process from other countries which is driving up costs. In the U.S., each payer has its own documentation requirements, creating a significant burden on providers to translate clinical documentation into billable codes for reimbursement, thus driving up costs, the study said. Because of standardization in other countries, providers spend less time coding or do not need coders to translate documentation into billable codes.
Review recent OIG activity, including a special fraud alert targeting contracts with telehealth companies.
The Office of Inspector General (OIG) has been busy lately. Review some of the latest OIG audits and reports to help ensure your organization is staying compliant.
Federal watchdogs say CMS still has not collected the nearly $500 million in Medicare overpayments identified in audits over a two-year period dating back to 2014.
The OIG at the Department of Health and Human Services did a follow-up review of 148 Medicare audits it conducted between October 1, 2014, and December 31, 2016, and could verify that CMS had collected only $120 million of the $498 million in overpayments.
In the recent audit, the OIG focused on seven groups of high-risk diagnosis codes, aiming to determine whether selected diagnosis codes submitted by Peoples Heath Network—a Medicare Advantage organization—for use in CMS’ risk adjustment program complied with federal requirements.
Federal officials have issued a special fraud alert targeting contracts with telehealth companies and offered seven characteristics of an arrangement that could be illegal.
The notice, issued by the OIG, follows several recent investigations into companies claiming to offer what they define as telehealth services, but which often constitute illegal marketing schemes.
Medicare and its beneficiaries paid considerably more at provider-based facilities than they would have for the same services at freestanding facilities, according to the OIG.
The OIG's audit examined $3.95 billion paid for evaluation and management (E&M) services at provider-based facilities from 2010 to 2017 in eight states: California, Colorado, Florida, Louisiana, Michigan, Missouri New York, and Texas. Based on outpatient and Physician Fee Schedule claims for E&M services performed at provider-based facilities, researchers compared the data to what would have been paid at freestanding facilities.
Automation has become commonplace in the revenue cycle, and as leaders look to remedy staffing issues, adding technology may be more important than ever.
Technology has started to play an even bigger role in the revenue cycle as staffing shortages seem to have hit a high.
To this point, more than 57% of health systems and hospitals have more than 100 open roles to fill, with one in four finance leaders needing to hire more than 20-plus employees to fully staff their revenue cycle departments, according to a recent survey.
Automation has been a clear solution to not only alleviating staffing issues in revenue cycle but making the administrative process more efficient overall. While, according to survey, the use of automation in revenue cycle operations increased in 2021 from 66% to 78%, there remains a demand for further implementation to relieve the burden on staff.
In fact, one recent revenue cycle leader HealthLeaders spoke to about its automation journey was Jamie Davis, executive director of revenue cycle management at Banner Health. Banner's journey in implementing the use of AI and automating its revenue cycle management wasn't an easy process, but it was necessary to protect the organization against revenue leakage.
Banner Health currently has 22 day-to-day bots helping with its revenue cycle management. These bots complete tasks like adding insurance information and updating medical records. "All the things that our human resources shouldn't waste their time doing," Davis said.
These bots manage roughly 90 million records for Banner Health, and from mid-2020 to 2021, Banner has saved about 1.73 million man-hours by deploying them, Davis explained. Banner Health also has machine learning in its refund and variance space to help with credit and debt balances.
When it comes to taking on such a large automation endeavor, partnerships are needed Davis says.
"Our automation is done completely in partnership with our IT group. They have their own robotic process automation center of excellence, but they've also started dabbling in some process mining in our health plan data. And we are working towards automating things like low balance accounts receivable management and denials," Davis says.
"The automation of the denials, low balance accounts receivable management, and the variances is really fun and innovative. That's where it's really rolling into that intelligent automation space since it's using machine learning that is predicting and reacting," Davis says.
So what can other revenue cycle leaders do when looking to streamline, or even implement, technology at their organizations?
To shed some light, Brenda L. Erley, CDEO, CPC, CCS-P, CPB, director of front and middle revenue cycle management services, at Strivant Health, recently spoke to Healthleaders on how revenue cycle leaders can better streamline technology, alleviate staffing issues, gain administrative buy-in, and see a ROI.
Healthleaders: Where are organizations seeing the biggest gaps right now and how can technology help improve them?
Brenda Erley: Due to staffing shortages, the need for assistance with coding denials and follow-up is probably the biggest gap we are seeing. When the technology is there to code accurately at initial claim review and submission, then the expectation would be a reduction in the need for coding denials and follow-up.
HL: What tips do you have for revenue cycle leaders looking to streamline their revenue cycle management?
Erley: Investing in AI and bots to assist wherever an organization can is paramount to streamlining an organization's revenue cycle management operations. This can help to alleviate the repetitive day-to-day tasks so team members can focus their energy and attention on more crucial revenue cycle operations. This can be anything from daily reporting to eligibility, charge entry, and coding.
HL: Revenue cycle leaders are faced with ample workforce challenges right now including both hiring and maintaining staff. How can technology help remedy this?
Erley: Technology doesn't get sick, it doesn’t take days off, it doesn't have to play catch up, it doesn't have bad days or good days. It is just there constantly working and processing consistently. Downtime is minimal, if non-existent, for technology, and this overall consistency helps to avoid those peaks and valleys we see in charges and reimbursement when there are disruptions in staffing.
HL: How can revenue cycle leaders position themselves best for administrative buy-in when looking to implement new technology?
Erley: Research the technology, and put the time into building, testing, and auditing. If you can, revenue cycle leaders should also have provider buy-in so they can be an advocate for documentation improvements within their organization to further enhance the success of technology. The time you put in at the beginning will reap greater results in the end. Technology is all about adoption. Without adoption from everyone including the physicians, administrators, and c-suite executives, organizations generally won’t see the ROI.
A recent survey focusing on the revenue cycle's health information management (HIM) department found that organizations are working on building HIM departments back up after deep cuts to staffing.
As revenue cycle leaders look to remedy staffing shortages within their HIM department, now is the time to examine the department's innerworkings in order to stay competitive within the market.
HIM staffing has rebounded over 2021's low, indicating that organizations are working on building HIM departments back up after the combined hits of deep cuts to staffing and hours and the great resignation, according to respondents of HIM Briefings' recently published HIM Director and Manager Salary Survey.
According to the survey, 15% of respondents lead departments with more than 150 full-time employees (FTE), compared to just 6% in 2021. That puts 2022 back on par with 2020, when 14% reported their HIM departments had 150 or more FTEs, according to HIM Briefings.
To put the survey results in context, respondents were asked about their job titles and facilities. Just under half (43%) of respondents indicated they're an HIM director or manager. Slightly more than one-quarter (28%) reported they hold a coding manager or director title.
Of those who hold an HIM director or manager title, 50% are an HIM director at a single facility.
Overall, 38% of respondents are employed by an acute care hospital. Of respondents from acute care facilities, 33% indicated their facility has 600 or more beds, and 38% reported their facility is located in a suburban area.
Salary
The 2022 survey also found that HIM director salaries saw gains over the last year, even as hospitals continued to face tighter budgets and fluctuations in patient volumes due to COVID-19.
In 2022, 87% of HIM directors and managers earn at least $70,000 annually, 80% earn at least $80,000 annually, and 52% earn at least $100,000 annually. That shows an overall pay bump compared to 2021, when 79% of HIM directors and managers earned at least $70,000 annually, 67% earned at least $80,000 annually, and 45% earned at least $100,000 annually.
Education and experience
Although many HIM directors have years of experience in the field, most are newer to their current role: 20% of respondents reported having 21-39 years of experience in the field and 24% have held their current position for three to five years.
According to the survey, 93% of respondents reported holding a post-secondary degree. In addition, 39% have earned a bachelor's degree, while 24% hold an associate degree and 24% have completed a master's degree.
According to the survey, respondents made the following amount according to education level:
Associate degree:
46% earn $50,000–$79,999 annually
30% earn $80,000–$99,999 annually
23% earn $100,000 or more annually
Bachelor's degree:
14% earn $50,000–$79,999 annually
38% earn $80,000–$99,999 annually
48% earn $100,000 or more annually
Master's degree:
8% earn $50,000–$79,999 annually
15% earn $80,000–$99,999 annually
77% earn $100,000 or more annually and 46% earn $150,000 or more annually
