Payers and difficulties with eligibility and prior authorizations keep patients from getting the care they need.
Seth Jeremy Katz (VP Revenue Cycle and HIM, University Health KC) discusses the difficult, and often frustrating, process of working with payers on eligibility and prior authorization claims.
Hospitals must add a footer at the bottom of their homepage with a link to the report.
Hospitals are now required to report price information in a “standard machine-readable” format, with data specification and a data dictionary.
The requirement is part of a price transparency rule enacted this week by the Centers for Medicare & Medicaid Services (CMS).
The new format, designed to make it easier for patients to understand hospital charges, is part of the 2024 Hospital Outpatient Prospective Payment System and ASC rule. Additionally, the rule mandates that hospitals add a footer at the bottom of their homepage with a link to the file, as well as including a .txt file in the website’s root folder.
Hospitals found to be out of compliance will receive a warning and be required to submit an acknowledgement of receipt.
As patients shoulder more of the cost for their healthcare, providers are feeling more pressure to ensure price transparency and abide by the No Surprises Act.
In February, CMS data showed that the number of surprise billing disputes had risen each quarter since the legislation went into effect. The majority of disputes, the agency found, came from a small group of providers.
Providers affected by the Change ransomware attack were tossed a lifeline and CMS tackles suspicious billing.
As the dust from a hectic first half of the year begins to settle, organizations are aiming for a strong finish. However, there are a few loose ends that need to be addressed.
Here are some revenue cycle news stories you may have missed.
Months after the Change Healthcare ransomware which disrupted the operations of providers across the country, many are still struggling to rebound. Some providers have been unable to begin the independent resolution process for out of network claims, being unable to access the information they need to proceed with billing.
The Biden administration, under the No Surprises Act, is giving providers until October 12 to begin the negotiation process for services provided this year, with the possibility of the deadline being extended.
To ensure patients and their care team have access to their health information, the Health and Human Services Department finalized a rule establishing penalties for health systems that prevent them from doing so. Various disincentives were also established to further dissuade providers from blocking patient’s access to information.
The rule, initially proposed in 2023, is backed by the 21st Century Cares Act.
The Centers for Medicare and Medicaid Services (CMS) proposed a new rule to address suspicious billing activity within the Shared Savings Program. The rule excludes payouts for codes relating to significant, anomalous, and highly suspect (SAHS) claims from being used to assess the financial performance of accountable care organizations.
The rule is part of larger plan to address anomalous spending in the program.
After noting a significant increase in highly suspect claims for Healthcare Common Procedure Codes (HCPCS), The Centers for Medicare & Medicaid Services (CMS) is proposing a new rule to crack down suspicious billing activity.
CMS officials have reported a significant increase in SAHS (significant, anomalous and highly suspect) claims for codes for urinary catheters, tips, and insertion supplies during 2023, and the corresponding HCPCS codes were flagged for SAHS billing.
The proposed rule will exclude payouts for codes A4352 and A4353 on DMEPOS claims from the expenditure and revenue calculations used to assess financial performance for accountable care organizations (ACO) for 2023. These calculations will also establish benchmarks for organizations starting agreements in 2024, 2025, and 2026.
The decision comes as part of a larger strategy to address SAHS claims within the Medicare Shared Savings Program, which will be explained further in the CY 2025 Physician Fee Schedule.
In a statement, Jennifer Holloman, the American Hospital Association’s senior associate director of policy, said the rule is a “significant” step to address anomalous spending, and it won’t be the last.
“We hope the upcoming CY 2025 Physician Fee Schedule will provide additional details to support longer term strategies to address anomalous spending,” she said.
According to CMS, the proposed rule could delay the disbursement of initial ACO payments for 2023 by up to six weeks.
The program offers a career path for neurodivergent individuals, enabling them to be more independent.
Medical coders are an integral part of revenue cycle operations. But with the ongoing workforce shortage and the level of expertise needed for the role, the talent pool of qualified candidates is small.
Tami McMasters Gomez, director of coding and CDI program at UC Davis Health, saw an opportunity to address it while integrating a cause close to her heart: Neurodiverse individuals finding fulling careers.
Working with the UC Davis MIND Institute, a center for the study and care of individuals with autism and neurodevelopmental conditions, McMasters Gomez has developed a small pilot program that includes a paid medical coding internship specifically designed for neurodivergent individuals. Being neurodivergent herself, Gomez said evidence shows many neurodivergent individuals have an affinity for tasks like data abstraction.
“It occurred to me that coding, which is really reviewing clinical documentation, abstracting that out and converting it to a numeric diagnosis or procedure code was in line with the skill sets that would accommodate [neurodiverse] individuals,” she said.
The program offers a career pathway to individuals who may not have had one otherwise, giving them the means to be more independent. The MIND Institute contributed infrastructure support and consultation on candidates for the program, which currently has two interns.
As the population of coders becomes more experienced it will open up more entry-level coding positions, and Gomez believes this program could help get younger generations interested in coding as well as helping the underrepresented neurodiverse population.
“The ability to work in a remote environment was a key aspect of this because many people in the neurodiverse space face challenges in social situations,” said Gomez, who was able to get much of the educational materials donated to the program. “This offers a unique workspace because most of the coding workforce today is 100% remote.”
The self-paced study portion of the pilot program will last approximately 12 weeks, with check-ins every week. Interns will then be assigned a mentor and begin coding cases in the EHR, as well as using a real encoder. This offers real-time experience to get familiar with the workflow and receive feedback on their performance.
After that, the program team assesses whether the intern is ready to sit for an introductory coding credential. The cost of sitting for the test is covered by the program.
The main challenge for the program is funding. Program leaders are monitoring the progress of the first two interns, making note of key performance indicators, including a base coding accuracy rate of 90% and productivity standards. They’ll also be measuring feedback from the candidates on their engagement and the program’s impact on their lives.
All of these factors will play a role in whether the pilot program is a success and will be extended.
Gomez is working with staffing agencies to help place interns in coding roles after the internship. As more people learn about the program, she hopes it will encourage more participation.
“I’m hoping this becomes a national program that supports organizational goals around DEI,” she said. “It supports those people in the neurodiverse space that might otherwise not have an opportunity."
It's crucial for health systems to have a business continuity plan in place.
In the event that business operations are disrupted, there needs to be procedures in place to redirect processes and get operations back online. Andy Talford (Senior Director of Patient Financial Services, Moffitt Cancer Center) shares some insights about his organization's efforts to develop downtime procedures.
The disincentives are held up by the 21st Century Cures Act.
The Health and Human Service Department has finalized a rule establishing penalties for health systems that block patients from accessing their health information.
Backed by the 21st Century Cures Act ,the new rule is meant to ensure that patients and their care teams have access to their health information, HHS Secretary Xavier Becerra said in a statement.
“When health information can be appropriately accessed and exchanged, care is more coordinated and efficient, allowing the healthcare system to better serve patients,” he said.
The new rule, which was initially proposed in October 2023, establishes the following:
Hospitals or critical access hospitals that have committed information blocking will not be classified as a meaningful EHR user during the calendar year of the EHR reporting period in which the HHS Office of the Inspector General (OIG) refers its determination to the Centers for Medicare & Medicaid Services (CMS).
A Merit-based Incentive Payment System (MIPS)-eligible clinician who has committed information blocking will not be a classified as a meaningful EHR user during the calendar year of the performance period in which OIG refers its determination to CMS. This includes group practices.
Providers that are involved in Accountable Care Organizations (ACO), ACO participants, or ACO providers who commit information blocking may be ineligible to participate in the program for a minimum of one year.
Those providers may also forfeit revenues they might otherwise have earned via the Shared Savings Program.
Each disincentive will be effective 30 days after the publication of the final rule. Those under the Shared Savings Program would go into effect after January 1, 2025. A notice from HHS announcing the rule’s finalization notes that additional disincentives may be established in the future.
The latest addition to the hospital is tasked with transferring lab specimens.
Of all of the mission partners at OSF HealthCare Saint Anthony’s Health Center, Dwight is the most unique. Why? He’s a robot.
Since May, Dwight has served as a pneumatic tube system, transferring lab specimens from the Emergency Department on the ground floor to the Lab on the first floor. Whereas this task previously took Mission Partners away from their respective units for a matter of time, they’re now able to spend more time on patient care.
“At first, I think there was a little bit of a [surprise], like ‘what’s this new thing roaming the halls,’” Traci Bromaghim, director of nursing practice and operations for emergency services, told HealthLeaders. “But once the education got out there, he’s been well accepted both from the Mission Partners and our community.”
Dwight was built by Pringle Robotics, a robotics company based in Peoria, IL, with his development funded by the donation of one of the hospital’s benefactors, who he’s also named after. Sarah Braundmeier, manager of laboratory services, and her team took the initiative to make him more personable, giving him eyes and a smile, equipping him with a nametag, and making him a Mission Partner.
Working with the robotics company and the hospital’s elevator company, they were able to program Dwight to be able to call for an elevator on his own and know which floors to go to. The learning curve for his utilization was short and he was used within his first hour at the hospital.
OSF Saint Anthony’s also has a contract with the robotics company where they will come fix Dwight if needed, along with continuing to enhance his capabilities.
“I have an app on my phone where I can reach out to them at any time to get him fixed,” Braundmeier said. “It’s having that constant communication with them to help us out so that it’s not just solely our responsibility to try to work through any issues that we might have.”
According to Bromaghim, Dwight is polite and interacts with people, telling them what he’s doing. Laboratory staff enjoy interacting with him and patients have been receptive to him as well. He makes an average of 50 trips to the hospital’s lab a day, with a total of 18,250 trips projected for his first year.
Jerry Rumph, president of the hospital, has seen the excitement around Dwight firsthand, from paramedics stopping in for a glimpse of him to other members of the system.
“I’ve been in meetings where people in our ministry, because we’re one of 15 hospitals, had been following [Dwight’s journey] on social media,” he said. “Everybody finds him to be quite intriguing.”
Health systems are struggling with a significant increase in denials from insurers.
During HealthLeaders' recent RevTech NOW Summit, Seth Jeremy Katz (Vice President of Revenue Cycle and HIM, University Health KC) explained how his system "never takes a denial lying down."
In the aftermath of the Change cyberattack, some providers are struggling to begin the process.
Months after the ransomware attack that halted operations for a substantial number of providers across the country, some are having issues beginning the independent dispute resolution process for out of network claims.
To help providers, the Biden administration—under the No Surprises Act—is giving them until October 12 to start the negotiation process for services provided this year. This timeframe could be extended, if needed, according to a CMS notice.
In addition to preventing them from providing services, the effects of the ransomware attack have delayed providers accessing the information needed to proceed with the billing process. Such information includes date of plan payment and coverage denials.
In March, UnitedHealth Group, Change Healthcare’s parent company, advanced over $2 billion to help providers whose revenue cycle operations were disrupted due to the attack. UnitedHealth also suspended prior authorizations for select outpatient services and utilization reviews of inpatient admissions for Medicare Advantage plans.
West Virgina-based Davis Health System was affected by the Change Healthcare attack, which negatively impacted their ability to provide care to its patient population.
“Without being able to get prior authorization and insurance verification, many patients do not want to take the risk of having their insurance not cover the procedure,” Catherine “Mindy” Chua, the system’s CMO previously told HealthLeaders.
The financial impact on the system was also significant. Unable to receive payments from insurers affected its amount of cash on hand. Claims had to be processed manually and revenue cycle staff had to hand-key claims since they were unable to use the system’s EHR.
