CMS is receiving pushback on its plan to create three new prolonged services codes.

Healthcare stakeholders, ranging from specialty societies to individual coding consultants, have urged CMS to abandon its plan to create three new prolonged services codes in comments submitted in response to the proposed 2023 Medicare physician fee schedule (MPFS).

Industry stakeholders described the three-code proposal for prolonged services as disappointing, burdensome, and confusing, according to Part B News.

For example, the American Association of Oral and Maxillofacial Surgeons said it was disappointed that CMS did not intend to accept the CPT® coding update to prolonged services and expressed concerns that two coding systems "will create administrative burden and undue confusion on the part of healthcare providers and coders."

The American Academy of Neurology predicted CMS’ proposed policy will "lead to confusion among practitioners and prove to be disruptive when medical specialty societies educate members about the correct coding for prolonged service."

Both specialty societies urged CMS and the workgroup to come to an agreement on how to define prolonged services for their revenue cycle.

According to Part B News, one commenter, a self-described professional billing consultant from Ohio, said the plan "makes no sense" and noted that it would not simplify coding. "If you are seeking 'administrative simplicity,' you should work it out with CPT and agree. The two of you having completely different numbers for the same [services] is going to be extremely confusing, " the commenter said.

CMS' original plan to use time to determine whether the treating physician or qualified health care professional (QHP) performed the substantive potion of a split/shared visit isn’t picking up any fans, based on a review of posted comments, Part B News said.

In the final 2022 MPFS rule, CMS said that it would allow practices to determine the substantive portion of the visit based on time or performance of key components for one year to allow providers to get used to the new policy. In the 2023 proposed rule, the agency announced plans to extend its policy another year.

However, the comments indicate that stakeholders want the option to bill based on time or key components—time or medical decision-making after 2022—to be permanent.

These aren't the first groups to urge changes of the rule.

Both the Medical Group Management Association and the American Hospital Association submitted comprehensive comments to CMS in response to the rule as well.

The associations urged Congress to provide a positive update to the conversion factor, finalize the proposal to align telehealth services, and adjust subgroup reporting requirements under the MIPS value pathways, among other changes for 2023.

"Practices and coding educators will have to wait for CMS’ final decision. The final fee schedule is expected to be out in early November. However, the key lesson is that practices should be aware of what CMS is planning and wait until the final rule comes out to train staff," Part B News said.

 

Shoring up technology has been a clear solution to alleviating staffing issues in the revenue cycle, and streamlining your current EHR system is a great place to start.

Electronic health record (EHR) systems are a critical to revenue cycles when looking to improve the patient experience and create better clinical outcomes, but revenue cycle leaders may need to rethink their optimization approach before it's too late as continued workforce shortages and supply chain disruptions may make it more difficult to enhance your EHR. 

Almost 60% of health systems and hospitals have more than 100 open roles to fill a recent survey spotlighted, with one in four finance leaders needing to hire more than 20 employees to fully staff their revenue cycle departments.

Shoring up technology and automation has been a clear solution to not only alleviating staffing issues in the revenue cycle but making the administrative process more efficient overall, and streamlining your EHR system is a great place to start.

Julie McGuire, managing director at the BDO Center for Healthcare Excellence & Innovation, spoke with HealthLeaders on why EHR systems need to be optimized now and how revenue cycle leaders can get started.

HealthLeaders: Why is it important for revenue cycle leaders to have an optimized EHR system?

Julie McGuire: Revenue cycle leaders have the opportunity to lead their organization in a time of continued disruption, marked by decreased cash flow, labor shortages, and the implementation of digital solutions. Having an optimized EHR maximizes the value of investments. It can decrease integration complexities and ensure staff members are working at the top of their capabilities effectively and efficiently. 

An optimized EHR can also help with optimizing revenue cycle functions, including improving work queues for faster actions on denials or referral responses and improving scheduling templates to open access. Another opportunity to reduce open encounters and lag charge time is to optimize clinical documentation tools and templates; this should also improve provider satisfaction and decrease provider moral injury. Taking the friction out of the referral process will lead to more satisfied referring providers and patients. 

HL: With staffing shortages at an all-time high, how can revenue cycle leaders leverage EHR technology to help with this?

McGuire: Taking advantage of automated workflows and activities where possible should help to reduce the impact of labor shortages. Optimizing dashboards and analytics on key metrics like denials can help leaders determine where staff should focus. EHR technology can also be used to boost the efficient use of the patient portal, so patients can take the lead on scheduling appointments, online check-in and arrival, paying bills online, and obtaining their records.

HL: What are some tips revenue cycle leaders need to know in order to streamline and optimize their EHR?

McGuire: There are a few main areas I would highlight:

First, be well-versed in the functionality your organization has implemented already but may not have been adopted in your department. 

Second, know the updates and features your EHR has available that will support organizational goals. Have conversations with your IT partners on the significance of implementing an effective EHR system to drive value for the organization.

And third, understand what your EHR can do to possibly reduce the need for a third-party system. It can reduce the overall application costs to the organization and decreases complexity for staff who may be working in multiple systems.

Remember, by optimizing its EHR, health systems are closing the value gap on the investment. Taking full advantage may improve operational efficiencies by decreasing integration complexity, reducing overall IT costs, and improving users' efficiency. And know that it doesn’t have to be expensive. Optimization doesn't have to mean overhauling your whole system.

HL: So then what incremental, low-cost changes can make a difference when looking to streamline?

McGuire: Break down your overall optimization plan instead of focusing on a large overhaul.

For example, first just focus on the patient experience and maximizing the patient portal. Another opportunity is to look at maximizing the reports/dashboards the EHR has to offer so concerns can be addressed right away. It's important to optimize the documentation and ordering tools for a high revenue generating specialty. Another option is to take a struggling specialty within your organization and optimize their documentation tools.

 

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.

Editor's note: This article appears in the September/October 2022 edition of HealthLeaders magazine.

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 August, including payment rate updates and revised COVID-19 billing guidance.

Here are the five updates you need to know.

Prepare for your organizations' payment rates to possibly change on October 1.

In August, CMS published the fiscal year (FY) 2023 IPPS final rule. CMS projects an increase in operating payment rates by 4.3% based on a projected hospital market basket update of 4.1% reduced by a 0.3% productivity adjustment and increased by a 0.5% statutory adjustment.

This operating payment rate is significantly higher than the 3.2% rate from April's proposed rule and follows a trend with the other final payment system rules released thus far in 2022 where the payment rate in the final rule is higher than that from the proposed rule.  

CMS finalized a return to using the most recent available data (including the FY 2021 MedPAR claims and the FY 2020 cost reports) for FY 2023 rate-setting with some modifications to account for any impact COVID-19 may have had. This includes calculating two sets of relative weights–one including COVID-19 claims and one excluding COVID-19 claims–and averaging those out to determine FY 2023 relative weight values. A full accounting of additional modifications CMS will make for rate-setting is discussed in the rule. 

Other policies finalized in the rule include: 

• Approving 25 technologies for new technology add-on payments for FY 2023, but not continuing with a one-year extension for certain new technologies that are out of their newness period despite the authority to do so due to the public health emergency.
• Due to certain statutory language and a recent federal court ruling (Milton S. Hershey Medical Center v. Becerra), CMS is modifying policies for teaching hospitals as well as for certain providers and cost years to address situations for applying the full-time employee (FTE) cap when a hospital's weighted FTE count is greater than its FTE cap.
• As it has in other payment system rules for FY 2023, CMS is finalizing a 5% cap on any decrease to a hospital's wage index from its wage index the prior FY. 

The rule also contains a variety of quality reporting program changes and several changes to policies regarding maternal health. CMS finalized a proposal to create a new "birthing-friendly" hospital designation effective fall 2023.

As mentioned previously, in April CMS proposed an IPPS increase of 3.2% for FY 2023, an additional $1.6 billion. However, that proposal drew flak from the hospital lobby. The Federation of American Hospitals (FAH) called the proposed increase "woefully inadequate."

"It does not reckon for the hyper-inflation, staffing crisis, and the continuing pandemic, which will impact resources necessary for patient care well into the future," FAH said in April.

However, the bumped reimbursement rate in this final rule "pleased" the American Hospital Association (AHA).

"This update still falls short of what hospitals and health systems need to continue to overcome the many challenges that threaten their ability to care for patients and provide essential services for their communities," AHA Executive Vice President Stacey Hughes said in a media release.

"This includes the extraordinary inflationary expenses in the cost of caring hospitals are being forced to absorb, particularly related to supporting their workforce while experiencing severe staff shortages," Hughes says. "We will continue to urge Congress to take action to support the hospital field, including by extending the low-volume adjustment and Medicare-dependent hospital programs."

The rule is effective October 1, 2022.

CMS is requesting information that may pertain to your revenue cycle.

Also this month, CMS published a request for information in the Federal Register regarding how Medicare can work to improve equity, high-quality, and person-centered care through Medicare Advantage (MA) in a way that is affordable and sustainable.

Some of the specific questions CMS asked for input on include effective approaches to handle social determinants of health, what types of supplemental benefits MA plans do or should provide, and how MA plans use prior authorization.

The use of data for MA plan and program improvement is also found throughout the request. Specific and detailed asks concern what can be done to better leverage data for better outcomes. Some examples include:

• The best data to advance equity. CMS seeks better data related to race, ethnicity, and language; sexual and gender identity; people with disabilities and language/communication hurdles; cultural identity and religious preferences; socioeconomic need; and people in rural and underserved communities.
• A focus on socioeconomic data. CMS adds specific questions, including MA plan challenges in "obtaining, leveraging, or sharing such data."
• Supplemental benefit use and outcomes. To improve both, CMS asks what "standardized data elements" it could collect and how they would also aid DOH, equity, and cost-sharing burdens. 
• Applications for utilization management (UM). With a Senate bill aimed to improve PA headed to the house, CMS wants to know which of its data, if any, help with UM/PA application and how MA plan data could align for better efficiency.
• Value-based contracting. Data to assess value-based contracting models within the MA program.
• Competition dynamics. CMS seeks data on vertical integration and its MA market impact.

CMS released more guidance for your revenue cycle staff on COVID-19 billing.

On August 16, CMS updated its FAQs for Medicare providers regarding COVID-19 billing. CMS published two new FAQs in the document regarding Medicare coverage and billing for COVID-19 testing done solely for travel purposes.

For example, CMS was asked if it is appropriate for a clinical laboratory to bill and accept cash payments from Medicare Part B beneficiaries for COVID-19 testing solely for the purposes of travel.

According to CMS' answer to this question, providers are required to submit claims for Medicare-covered services. However, in general, if a service is not covered by Medicare because it is not within the scope of a Medicare benefit, providers may bill and accept direct payments from beneficiaries for those services.

CMS said it strongly encourages providers to issue an advance beneficiary notice of noncoverage for care that is never covered because it does not meet the definition of a Medicare benefit, including COVID-19 testing performed solely for the purposes of travel.

Did CMS just lighten the load for your revenue cycle staff?

On August 17, CMS announced it is discontinuing the use of certificates of medical necessity and durable medical equipment information forms for claims with dates of service on or after January 1, 2023.

CMS said it reached this decision due to stakeholder feedback that these forms are duplicative and burdensome, and CMS said that submission of these forms is particularly burdensome for small or rural providers.

Another OIG audit highlights the importance of accurate coding.

On August 23, the OIG published a review of whether select diagnosis codes that Cigna HealthSpring submitted to CMS for use in the risk adjustment program complied with federal requirements.

The OIG conducted the audit by sampling 200 enrollees with at least one diagnosis code that mapped to a hierarchal condition category (HCC) for 2015. This resulted in 1,470 HCCs associated with these enrollees. The OIG found that 69 of the 1,470 HCCs were not supported in the medical record, a far lower error rate than the OIG typically finds in these audits.

The OIG also found that there were an additional 18 HCCs for which the medical records supported diagnosis codes that Cigna HealthSpring should have submitted to CMS but did not.

Therefore, the risk scores for these sampled enrollees should have been based on 1,426 HCCs instead of 1,470, and Cigna HealthSpring received $39,612 in net overpayments for these sampled enrollees. 

The OIG recommended that Cigna HealthSpring refund the federal government for the $39,612 in net overpayments and improve its policies and procedures to prevent, detect, and correct noncompliance with federal requirements for diagnosis codes used in risk-adjusted payment calculations.

Cigna HealthSpring disagreed with the OIG's findings and recommendations from the draft report and questioned the OIG’s audit and statistical sampling methodologies. The OIG revised some of its original findings and recommendations but maintained that its methodologies were reasonable and properly executed.

 

As more claims roll in and staffing needs deepen, revenue cycle leaders should work on solutions to make up for potential lost revenue.

Patient volumes and subsequent claims will only continue to increase. In fact, medical claims are now on the rise after being suppressed during the early stages of the COVID-19 pandemic.

On top of this, there is mounting pressure on hospital margins. Between June and July of this year, hospitals' financial performance plunged, according to the latest National Hospital Flash Report from Kaufman Hall.

As healthcare organizations look to strengthen the bottom line coming out of the pandemic, it will be increasingly important for leaders to address revenue cycle management gaps—and do so while balancing the lack of staffing.

Belinda Cridge, revenue cycle management expert at HGS Healthcare, spoke with Healthleaders to discuss what revenue cycle leaders can do to alleviate these issues as pressure intensifies.

Increasing revenue and closing gaps

"With inflation at a 40-year high everyone has less buying power, which will likely result in a larger volume of self-pay, accounts-receivable balances." Cridge says.

This is why it's important for revenue cycle leaders to develop processes to collect payments pre-service and provide patients with better good-faith estimates.

"Another area of revenue loss is typically retro-eligibility and coordination of benefits. Developing exception reports, retro-eligibility reports, and paid-claim databases are some of the best ways to avoid black holes as it relates to this area of loss," Cridge said.

Pinpointing the area within your revenue cycle with the most gaps is also very important.

Within revenue cycle management, clinical denials for medical necessity and level of care downgrades are costly. Post-pay audits were temporarily put on hold during COVID-19, and now organizations are seeing a huge rise in these audits, Cridge says.

"Data science and analytics can help providers track root causes of unpaid claims and avoid these going forward," Cridge says. "Payer rules are cumbersome and some providers, by matter of routine process, provide certain levels of service irrespective of the payer."

While creating a plan of action for revenue cycle leaders is a great start, it can seem like an uphill battle as revenue cycle staffing shortages take hold.

According to a recent survey, more than 57% of health systems 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.

Since staffing and revenue cycle talent shortages will continue in the near-term and exacerbate the pressure on cost reduction, Cridge says she recommends three steps to immediately enhance the revenue cycle to help increase the bottom line and ease staffing deficiencies.

One: Invest in a consultative review of accounts receivable to identify the top three to five areas causing the most revenue bleed and develop plans and timelines to fix them.

For example, billing processes—from bill creation through payer acceptance—can greatly benefit from being fully automated, Cridge says. 

"Automating these processes are typically inexpensive and can have an immediate impact on revenue," she said. 

Two: Review your small balance write-off policies. 

"It's easier to get small balance claims paid if there's a vendor partner who has robust services and the depth of experience to monitor and work through these efficiently," Cridge said.

Three: Develop post-pay audit processes by payer. 

Significant dollars are lost due to upfront tasks not being done to avoid recoupments, Cridge said.

Cridge has put her own tips to work as she recently helped to leverage data analytics to identify trends in denials/underpayments for an organization. 

The initial findings showed that, over a period of two years, one payer underpaid $120K in oncology payments, while another payer did not pay a single appeal, she said. Cridge also found that there were 14,000 unnecessary follow-up attempts on claims that were being processed to pay. 

"Revenue cycle leaders should invest in a data center, a data scientist, and revenue cycle subject matter expert to help make up lost revenue. The initial set-up may be overwhelming, but the ongoing control will reduce the need for manual trending, alleviate staffing issues, and avoid revenue loss," she says.