As hospitals face tremendous financial pressures and regulatory burdens, leaders need to work hard to ensure their departments' success, and each leader has a unique way of doing just that.
It's no secret that hospitals are facing unprecedented financial pressures and regulatory burdens, and leaders organizationwide are working hard to keep their departments above water. In HealthLeaders' newest series The Exec editors touch base with leaders from every facet of an organization about triumphs and struggles within their role.
Check out some of the recent spotlights you may have missed pertaining to leaders and their work in surrounding the revenue cycle.
The Exec: Health Systems Succeed with Effective Outpatient Strategies
Outpatient care is essential to drive value in healthcare, says Tiffany Smith Sullivan, MPH, senior vice president and chief operating officer of physician services at NYP.
"To drive value at its core, you need a patient-centered approach. We need to build teams for patients that manage complex types of care, so that we are aligned, we are communicating, and we are working with the patient to make sure that they have everything they need to remain healthy in the ambulatory setting. For example, we want a patient who is managing diabetes to not have to go to the emergency department or have an inpatient stay. That is a condition that we can manage in the ambulatory setting with community partners to help the patient get what they need to stay healthy."
The Exec: Breaking Free From 'Button-Mashing' Through Revenue Cycle Automation
How to best leverage revenue cycle technology is something organizations are learning on the fly. But for healthcare leaders and workers, it's just as important to understand what technology can't and shouldn't do.
Tackling those misconceptions is critical, explains University Health's vice president of health information management and revenue cycle Seth Katz.
The Exec: Henry Ford Health CFO Discusses Plans for Hospital's Financial Success
Hospitals and health systems are eager to put the pandemic behind them, and while the physical devastation may be slowing, its impact, along with the labor crisis, rising expenses, and inflation are still taking its toll on healthcare providers.
Robin Damschroder, the CFO for Henry Ford Health—the Detroit-based healthcare provider with $6.8 billion in total patient revenue—is at the forefront of the fight to regain the health sector's financial stability.
CMS released the 2023 OPPS final rule that includes increased Medicare reimbursement and the establishment of a new provider type, but hospital groups say it's not enough.
CMS recently released the 2023 OPPS final rule, which brought increased hospital outpatient payment rates, the establishment of a new provider type, and 340B payment finalization.
According to the final rule, CMS has increased Medicare reimbursement for hospital outpatient departments by 3.8%, reflecting a hospital market basket increase of 4.1 percent and a 0.3 percentage point decrease for productivity. This is higher than the 2.7% update included in the proposed rule earlier this year.
Blow-back from the proposed payment rate increase of 2.7% may have played a role in the finalized amount of 3.8%.
At the time, the American Hospital Association (AHA) Executive Vice President Stacey Hughes said, "We are deeply concerned about CMS' proposed payment update of only 2.7%, given the extraordinary inflationary environment and continued labor and supply cost pressures hospitals and health systems face."
While more than what was proposed in July, the AHA doubled down on its original sentiment regarding the payment rate increase.
"While the AHA is pleased that CMS will provide hospitals and health systems with an improved update to outpatient payments next year compared to the agency's proposal in July, the increase is still insufficient given the extraordinary cost pressures hospitals face from labor, supplies, equipment, drugs, and other expenses," Hughes said in the AHA's OPPS final rule statement.
"As we urged, CMS will use more recent data in its calculations on the payment update, resulting in more accurate data that better reflects the historic inflation and tremendous financial pressures hospitals and health systems have confronted recently. However, hospitals are still dealing with a wide range of challenges in providing care, which is why the AHA is urging Congress for additional support by the end of the year," Hughes said.
Also finalized in the OPPS was the introduction of the rural emergency hospital (REH) designation. Converting to REHs can help critical access hospitals and small rural hospitals avoid closure and maintain access to care in rural and underserved communities, CMS said. The rule finalized proposals related to REH payment, covered services, conditions of participation, and quality measurements.
CMS Administrator Chiquita Brooks-LaSure said in a press release that "CMS is committed to expanding access to care in rural communities and ensuring people with Medicare get the high-quality care they need."
Also in the final rule, clinical staff in hospital outpatient departments are now permitted to provide remote behavioral health services to patients in their homes.
"Through the establishment of Rural Emergency Hospitals, supporting clinic visits at rural sole community hospitals and enabling people with Medicare to remotely access behavioral health services in their homes, today's actions promote patient safety, equity, and quality for these underserved communities," Brooks-LaSure said.
We can't forget the turmoil facing 340B payments.
In the OPPS final rule, CMS solidified the payment policy for 2023 of average sales price of 6% for drugs and biologicals acquired through the 340B program because of the unanimous Supreme Court decision earlier this year.
As for your revenue cycle staff, CMS will continue its requirement that 340B hospitals report drugs purchased under the 340B program using either the -JG or -TB modifier depending on the type of 340B hospital you are.
Robin Damschroder, the CFO for Henry Ford Health, recently shared with HealthLeaders the impact that these regulatory updates have on hospitals.
"There's a lot of pressure—as there always has been—on reimbursement rates. Henry Ford Health system and a lot of folks rely on 340B discounts and other mechanisms like disproportionate share payments. We're a big teaching institution, so a lot of these special payments that we do in order to teach the healthcare leaders of the future or make sure that we can take care of vulnerable patients are extremely important," Damschroder said.
"So that is an area that we and others are actively—in our advocacy—ensuring that these programs stay intact or evolve to a place that enhances the programs for the people that were trying to care for," said Damschroder.
Price transparency adherence data has been a mixed bag lately, so HealthLeaders reached out to an expert to understand why and figure out how revenue cycle leaders can help.
An October price transparency impact report highlighted a positive trend in hospitals adopting the law. According to the report, 76% of hospitals have posted a machine-readable file, 65% have posted a machine-readable file with negotiated rates, and 63% have posted a machine-readable file with cash rates.
While that report shows a progressive trend toward price transparency adoption, other reports have had the opposite to say just this year.
Sifting through studies like these can be as confusing as the regulation itself.
To give context to these studies and why revenue cycle leaders are seeing such varied numbers in price transparency adherence, HealthLeaders touched base with Chris Severn, CEO of Turquoise Health, to help break down the complexities of the matter.
Turquoise Health is no stranger to price transparency as it works through this data daily for its patient-friendly platform that lets patients compare providers, the costs of services, and health systems to make more informed choices for care.
HealthLeaders: Price transparency studies like this are being published left and right, but why are we seeing such large variances in these numbers across the board?
Chris Severn: At a high level, in the CMS mandate, hospitals must follow strict guidelines to be fully compliant. The placement of the patient estimate tool on the hospital’s website, the naming convention of machine-readable files, and the use of plain language (language that patients can easily understand) to describe a healthcare service are all defined and required within the rule.
Because of the vast array of guidelines included in the rule, it’s not uncommon to see findings similar to JAMA that are focused on “all price transparency requirements.” On the other hand, Turquoise Health’s studies lean more on the contents of the machine readable files and less or not at all on the patient estimate tool. That variance in the specific areas of focus leads to different estimates of adherence based on differing factors.
HealthLeaders: You have said you expect the timeline for total price transparency adherence to take about five years. Why is this? Is it due to staffing shortages or a lack of automation?
Severn: Staffing shortages and a lack of automation are certainly straining hospitals. On the whole, though, the healthcare industry is very slow to change, and these price transparency laws are still new and changing.
The first waves of data are out and making an immediate industry impact, and down the line, we see that data starting to infiltrate other parts of the industry as well. As the adoption of the current rules and laws continues to increase, we believe that data will inspire positive changes, such as transparent contracting and less variability in pricing. Both of those would in turn help move the needle closer to fair prices of services, but those positive effects take time.
Pictured: Chris Severn, CEO of Turquoise Health. Photo courtesy of Turquoise Health.
HealthLeaders: Why is it so important that we get 100% of hospitals to comply with every facet of this regulation?
Severn: This ties back to the first question regarding CMS’ strict guidelines for compliance. The higher percentage of completeness regarding the publication of machine-readable files and accurate patient estimate tools, the closer we are to empowering patients to gain confidence in knowing how much their healthcare services will cost. Adherence from both hospitals and payers also eliminates a significant burden of negotiating new rates because all rate data will be publicly available, meaning fair rate calculation becomes simpler and accessible.
Overall, these lead to lowering the cost of healthcare.
HealthLeaders: What are some tips that revenue cycle leaders can keep in mind when looking to shore up price transparency adherence?
Severn: Make sure that you have a good understanding of the laws and requirements. There are a lot of resources out there that can help you get educated and understand where you and your organization can best focus your time.
Also, keep an eye on the landscape for information. We’re seeing guidance, training, podcasts, and notice of any changes, such as a recent job aid to assist payers and providers with their Independent Dispute Resolution applications, published nearly weekly.
HealthLeaders: What do you see coming in 2023 in terms of price transparency and other No Surprises Act regulations? What should organizations be on the lookout for?
Severn: We expect more changes to come in 2023. CMS currently has a request for an information period open specifically related to the creation of advanced EOBs (a part of the No Surprises Act). That request for information period is set to close in the middle of November, and we expect further guidance from CMS on how a fully compliant advanced EOB is defined. We also hope to see CMS issue a standard schema for hospital machine-readable files, similar to the Transparency in Coverage requirements for payers, and the move to a standard schema would simplify users’ ability to compile rate data.
The Patient Estimate Tool requirement of Transparency in Coverage also begins on January 1, 2023. This puts transparency data in the hands of all insured patients, at scale, and expands beyond just hospital prices (as we saw in 2021).
We expect payer data will become more mainstream as payers fix initial hiccups, respond to quality assurance pressure, and simplify their monthly publication process. Ideally, non-hospital providers begin to proactively surface prices as their data becomes public through the payer data.
Startups (payers, providers, and software companies) continue to pop up and receive funding to innovate on the employer and patient financial experience.
As hospitals face more financial troubles and turn the focus toward ROI, many revenue cycle leaders have been developing revenue integrity departments to help remedy revenue leakage.
To uncover the scope and depth of revenue integrity professionals’ impact on their organizations and revenue cycle, the 2022 State of the Revenue Integrity Industry Survey Report, released by the National Association of Revenue Integrity (NAHRI), collected information on industry trends and departmental functions.
Revenue cycle leaders know the value of data. Understanding how traditional revenue integrity functions, such as chargemaster maintenance, are performed across the industry helps set standards and expectations.
As revenue integrity departments continue to grow, it’s essential for revenue cycle leaders to keep an eye on emerging trends and opportunities that allow their revenue integrity professionals to keep pace with change.
The survey, which alongside revenue integrity staff also collected responses from hospital CEOs, CFOs, presidents or vice presidents of revenue cycle, and revenue cycle directors, asked respondents to define their revenue integrity program’s level of involvement in a variety of revenue cycle functions.
Respondents specified whether each function is primary in their program, handled as a support function, or is not handled at all.
The top primary functions reported were as follows:
Chargemaster maintenance (71%)
Correcting claim edits (53%)
Charge capture (52%)
Education (48%)
Charge reconciliation (44%)
Chargemaster maintenance, charge capture, and charge reconciliation are key components of a revenue integrity program, Lisa Stein-Pierce, director of revenue cycle operations at Maine General Health in Augusta, Maine, said in the report.
While revenue integrity departments are usually created to prevent recurrence of issues that can cause revenue leakage and/or compliance risks, they still provide key support to other revenue cycle departments in a variety of functions. The following were some of the most commonly reported support functions:
Charge reconciliation (45%)
Decision-support functions (44%)
Charge capture (40%)
Coding (40%)
Denials management (39%)
Clinical staffing issues may require revenue integrity departments to provide support for charge reconciliation, according to Shawishi T. Haynes, EdD, FACHE, director of revenue cycle, managed care, and revenue cycle integrity at Valley Presbyterian Hospital in Van Nuys, California. This means the revenue integrity team needs to handle the analytics, run the reports, and identify any anomalies in the data.
What are other revenue cycle leaders focusing on for the future of these departments? According to NAHRI’s report, the top revenue integrity initiatives for 2022 and beyond include:
Ninety percent of medical practices reported that the payment cuts found in the 2023 Medicare physician fee schedule would reduce access to care, the MGMA says.
Physician payment cuts are coming, significant changes to E/M services are finalized, and key reporting revisions are hitting telehealth and audio-only services, according to the final 2023 Medicare physician fee schedule.
Proposed payment cuts that drew vocal criticism from physician advocacy groups will move forward as planned, as CMS announced a 4.5% reduction to the 2023 Medicare Part B conversion factor (CF), effective January 1.
The CF will fall to $33.0607 in 2023, down from $34.6062 in 2022, largely due to budget neutrality adjustments. The final CF for 2023 is two cents lower than the rate CMS first proposed in July, according to Part B News.
The anesthesia conversion factor will also take a hit next year, down 4.4% as proposed.
Much like what we heard from the proposed rule, medical groups are not faring well with the finalized rule.
"As expected, CMS finalized a substantial reduction to the conversion factor — negatively impacting physician reimbursement across the board. It is more critical than ever that Congress act to avert these cuts, as well as the 4% PAYGO sequestration, before the end of the year," MGMA Senior Vice President Government Affairs Anders Gilberg said in a release.
"Ninety percent of medical practices reported that the projected reduction to 2023 Medicare payment would reduce access to care. This cannot wait until next Congress—there are claims processing implications for retroactively applying these policies," Gilberg said. "MGMA looks forward to working with both Congress and the Administration to mitigate these cuts and develop sustainable payment policies to allow physician practices to focus on treating patients instead of scrambling to keep their doors open."
Jack Resneck Jr., M.D. president of the American Medical Association (AMA) noted the same grievances and doubled down on the negative impact to access to care.
"The Medicare payment schedule released today puts Congress on notice that a nearly 4.5 percent across-the-board reduction in payment rates is an ominous reality unless lawmakers act before Jan. 1. The rate cuts would create immediate financial instability in the Medicare physician payment system and threaten patient access to Medicare-participating physicians. The AMA will continue working with Congress to prevent this harmful outcome," Resneck said.
Updates to E/M, telehealth, and more
CMS confirmed in the final rule that it will adopt the framework of the AMA’s revised E/M guidelines for facility and residential visits, including payment based on medical decision-making or time.
CMS intends to adopt the telehealth waiver extension that Congress passed in Consolidated Appropriations Act of 2022. The extension locks in a wide range of telehealth waivers for 151 days after the PHE expires, including the audio-only exceptions that have been popular with providers; the waiver of geographic and other limits ordinarily required for telehealth services; and the ability of therapists, occupational therapists, speech-language pathologists, and audiologists to bill such codes under telehealth.
For the Merit-based Incentive Payment System (MIPS), the category weight in 2023 will be 30% for Quality, 30% for Cost, 15% for Improvement Activities, and 25% for Promoting Interoperability. The data completeness threshold rises from 70% to 75%.
CMS will take applications for the MIPS Value Pathways (MVP) program that will eventually replace the current MIPS structure. The agency will also add five new MVPs to the seven in its MVP inventory.
As proposed, CMS will front money to ACOs with low revenue that treat underserved communities with advance investment payments (aka advance shared savings payments). The agency also will provide "greater flexibility in the progression to performance-based risk" to some ACOs, a CMS press release says, "allowing these organizations more time to redesign their care processes to be successful under risk arrangements."
CMS also will extend its incentive for voluntary reporting of eCQMs/MIPS CQMs through performance year 2024 (at which time it will replace the Web Interface reporting method for all Shared Savings ACOs) and institute a "health equity adjustment" for Medicare Shared Savings Program (MSSP) performance reporting.
"Premier applauds CMS for finalizing reforms to certain aspects of the MSSP that incentivize provider participation. As Premier has long advocated, we must ensure that providers in ACOs have an adequate budget, and that we create incentives for rural and other vulnerable providers to move to value, " Soumi Saha, senior vice president of government affairs at Premier, said in a release. "We remain disappointed, however, that CMS is continuing to distinguish between low- and high-revenue for ACOs, especially in light of a Premier analysis demonstrating the differences between ACOs have more to do with cherry picking locations and attribution methodology than with real performance," Saha said.
National Association of ACOs (NAACOS) President and CEO Clif Gaus, Sc.D., had a similar sentiment.
"Today’s finalized changes to Medicare’s largest ACO program bring a win to patients and will absolutely help providers deliver accountable care to more beneficiaries. NAACOS thanks CMS for its leadership and following through on its promise to create a stronger Medicare program by improving accountable care models and speeding the movement toward value for all patients. On balance, we believe this final rule will grow participation in accountable care organizations, which have already generated billions of dollars of savings for our health system," Gaus said.
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 October, including a CMS audit and payment adjustments for low-volume hospitals.
Here are the five updates you need to know.
The OIG said CMS' oversight of hospital compliance needs work.
The Office of Inspector General (OIG) released a reportin October to assess the results of 12 Medicare hospital audits from 2016 through 2018 and identify CMS' actions as a result of OIG recommendations made in those audits. The OIG explains that while CMS has taken some actions to ensure that the recommendations were implemented, it could strengthen internal controls to prevent payment of certain high-risk claims.
The 12 audits identified more than $5 million in overpayments by CMS, with 54 of the 387 improperly paid claims identified as outpatient claims that resulted in $53,729 in net overpayments.
The OIG report further explains that the most frequent mistake behind the outpatient claims being improperly paid was due to the implementation of incorrect HCPCS codes. Roughly 56%, 30 of the 54 improperly paid outpatient claims, had this problem.
“These errors included claims with HCPCS codes that were not supported by the medical records and claims with the improper number of units billed,” the report states
The second-most frequent reason for overpayments was the incorrect implementation of bypass modifiers. 17 of the 54, or 31% of the audited claims had this issue.
The document also identified that improper reporting of units for services was a reason for overpayment. This problem affected four of the 54 checked claims, or 7%. The hospitals incorrectly coded for multiple units of outpatient surgery procedures when they should have billed for only 1 unit.
The last 6% of the improperly paid outpatient claims were attributed to incorrect skilled nursing facility (SNF) consolidated billing.
The OIG made 36 recommendations as a result of the audits to CMS to “improve program oversight.” The most significant recommendations that the OIG provided to CMS were:
Continue to follow up on overpayment recovery
Improve tracking and responding on the status of claims identified in OIG reports as they proceed through the appeals process
Other recommendations included exercising diligence to identify, report, and return any overpayments in accordance with the 60-day payment rule, and strengthening internal controls to ensure full compliance with Medicare requirements.
CMS concurred with some of the recommendations and partially followed them. The OIG's report says that CMS provided “insufficient information” that it had implemented the recommendations to providers to repay overpayments. CMS asserted that it has consistently provided information as claims go through appeals processes with the OIG teams through the Audit Management System.
In response to the strengthening of internal controls, CMS directed its hospitals' MACs to perform self-assessments. However, the OIG reported that only four of the 12 originally audited hospitals completed the self-assessments and repaid their overpayments by the 60-day payment rule deadline.
Ten of the 12 originally audited hospitals took action to strengthen internal controls by implementing quarterly reviews, hiring external firms to audit, and providing additional training to coding and billing staff.
CMS released the 2023 Medicare Advantage and Part D star ratings.
On October 6, CMS published anews alert regarding the star ratings for 2023 Medicare Advantage and Part D Prescription Drug Plans.
Approximately 51% of MA plans that offer prescription drug coverage will have an overall rating of four stars or higher in 2023, while 72% of people currently in MA plans with drug coverage are enrolled in a plan that earned four or more stars.
The average star rating for all Medicare Advantage plans with prescription drug coverage is 4.15% for 2023, a decrease from the 2022 average of 4.37%. The number of five-star contracts fell significantly from 74 in 2022 to 57 for the coming year.
Overall, there are 67 contracts that earned 4.5 stars (96 last year), 136 that earned four stars (152 last year), 116 that earned 3.5 stars (122 last year), and 90 that earned three stars (25 last year).
The decline in ratings for 2023 isn't necessarily performance-based, as CMS adjusted its methodology to account for the COVID-19 pandemic no longer being at the height it was in recent years.
CMS published a fact sheet on the star ratings on the same date.
CMS is vacating the differential payment rate for 340B-acquired drugs in 2022 OPPS final rule.
On October 13, CMS published a note in MLN Connects regarding the ruling prohibiting CMS from applying a different payment rate for 340B-acquired drugs at average sales price (ASP) minus 22.5%. CMS will revert to paying the default rate (ASP plus 6%) for these drugs for the rest of the year.
CMS will also reprocess claims that the CMS contractors paid on or after September 28, 2022, using the default rate.
Biden-Harris administration strengthens oversight of nation’s poorest-performing nursing homes.
On October 21, CMS published a press release regarding updates to the special focus facilities (SFF) program to toughen requirements for completion of the program and increase enforcement actions for facilities that fail to demonstrate improvement. These updates are part of a series of actions this administration is undertaking in an attempt to increase accountability of bad actors in the nursing home industry, improve quality, and make nursing homes safer. There are currently 88 nursing homes in the country participating in the SFF program.
CMS published a memorandumdiscussing the specific changes to the program on the same date.
Are you a low-volume hospital? You may be catching a payment break.
On October 21, CMS published one-time notification regarding implementation of an extension for the low-volume hospital payment adjustments and Medicare Dependent Hospital (MDH) programs under the Continuing Appropriations and Ukraine Supplemental Appropriations Act of 2023.
The low-volume hospital payment adjustments and MDH programs that were originally supposed to end on October 1, 2022, have now been extended through December 16, 2022. These changes may affect designations of MDH programs as sole community hospitals in certain circumstances, and low-volume hospitals must send written requests to their MACs by November 16 to receive the applicable low-volume percentage increase for payments for FY 2023 discharges occurring before December 17.
CMS published MLN Matters 12970 on the same date to accompany the transmittal.
Review 3 Takeaways from the 2022 HealthLeaders RevTech Exchange.
Editor's note:This article appears in the March 2023 edition of HealthLeaders magazine.
Revenue cycle leaders face a dilemma: Either automate or risk having someone else do it for them. Once on the path to automation, leaders are faced with a set of balances and decisions that can either optimize or diminish the result.
Balancing automation and technology, along with workforce and strategy, were top of mind for the executives attending the 2022 HealthLeaders RevTech Exchange in Boston.
It's no question that automation is inexorable. But how it is deployed, and how the team shifts because of it, were among the connecting points at the event, along with these three takeaways:
Don't pave your goat path
Technology can support revenue cycles in centralizing and organizing data, allowing for greater transparency and performance, but while technology and automation are necessary, it doesn't work miracles.
As Derek Dudley, AVP of revenue cycle at Wellstar Health System said, "don't pave your goat path," an ages-old axiom for not applying new technology on top of a winding, bumpy process.
The use of technology and automation can improve efficiencies in claims processing, reduce the cost to collect, improve the patient experience, and beyond. And while revenue cycle staff can better understand systemic problems and deploy efforts to correct the root causes of revenue loss through technology, you can't expect it to be the sole fix to your problems, leaders said at the Exchange.
"Technology isn't always the fix. You can't just slap tech on top of broken processes hoping to fix them," said Chris Johnson, vice president of revenue cycle management for Atrium Health.
Significant time and energy need to be spent streamlining your workflow and mending broken processes before you can bring in new technology and automation, especially if you want it to work.
Don't expect to replace all FTEs with automation
Upskilling or reskilling revenue cycle staff to fill gaps instead of just automating processes is key, leaders say. Automation is great, but leaders said they are finding that it doesn’t necessarily negate the need for that human touch.
With staffing shortages, revenue cycle leaders are looking internally to leverage the potential of their workforce to work across various roles, and that’s not something technology can always achieve.
"We thought we could use tech to replace FTEs, but it actually made the case that we need more staff to touch what automation can't," said Jennifer Johnson, divisional director of utilization management at Advent Health.
By realizing the potential of the existing workforce, organizations can increase retention while also meeting financial goals. Rather than replacing staff with automation in the front, middle, or back end, leaders find it helpful to upskill or reskill to support revenue cycle functions that still work best with a human touch.
Don't let vendors off the hook
Leaders at the event explained that they are constantly approached by vendors promising to fix their problems—before even knowing what their problems are.
Because revenue cycle leaders are constantly bombarded by new solutions and technology, they need to be sure the solution is the right fit.
Some of the leaders at larger health systems said that they now build a test period into their contracts with vendors for new technology. A few of those leaders have had vendors run new technology (at no cost to the health system) for almost a year before an official go-live in order to ensure the solution actually works for them.
Revenue cycles are robust and complex, so making sure automation and technology works efficiently across the continuum is key.
"For physicians, our biggest concern is time. If new technology is slowing us down or adding more work, we aren't going to be on board," said Trey La Charite, MD, medical director of CDI and coding, at UT Medical Center. Without ample support from those middle revenue cycle teams, automation won’t be successful no matter how innovative it is.
Ensuring organizations have time to test technology, confirming it can work across all revenue cycle teams, and making sure you see positive results—all before an official go-live—is what has guaranteed an ROI for these leaders.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
Health systems are not the only entities now being held accountable for upholding price transparency.
The OIG recently announced it will be assessing CMS' monitoring and enforcement of the hospital price transparency rule. This audit, the OIG says, is expected to be released next year.
"We will review the controls in place at CMS and statistically sample hospitals to determine whether CMS' controls are sufficient to ensure that hospital pricing information is readily available to patients as required by federal law," said the OIG.
The OIG will also evaluate the extent to which CMS enforces the rule. CMS previously said hospitals in noncompliance with one or more of the rule's requirements may receive a written warning notice, a request for a corrective action plan, and civil monetary penalties (CMP).
The clock started in January of 2021 when the first of three different rules and laws that dictate price transparency went into effect.
Adherence to the regulation has been off to a slow start as many organizations site administrative burdens and revenue cycle workforce shortages as the cause to slow adoption.
"If hospitals are not in compliance with CMS' rule for listing their charges, we will contact the hospitals to determine the reason for noncompliance and determine whether CMS identified the noncompliance and imposed consequences on the hospitals," said the OIG on its upcoming audit.
When first shoring up price transparency processes, there are two main requirements that organizations need to adhere to immediately, Connie Lockhart, director of strategy and operations at Impact Advisors, previously shared with HealthLeaders.
"Revenue cycle leaders need to first make sure they are following CMS' guidelines to complete a comprehensive, machine-readable file of all services and items," she says.
"Ensure all requirements are met—like how a separate file must be posted for each hospital. And be cognizant of multiple hospitals operating under a single hospital license with different sets of standard charges."
Also, ensure that list is posted on a publicly available website.
Once completed, make sure to post a display in a publicly available website of 300 shoppable services in a consumer-friendly format. This should include the 70 CMS-specified, shoppable services, Lockhart says. Revenue cycle leaders should also establish a cadence to ensure both displays are updated annually, Lockhart says.
A handful of medical associations and groups show support to the Texas Medical Association (TMA), again.
The TMA recently filed another lawsuit stating that the surprise billing final rule independent dispute resolution (IDR) process still fails to comply with the No Surprises Act statutory text.
The new TMA suit is filed in the same Texas Federal Court that ruled in favor of the TMA earlier this year. That ruling vacated parts of the IDR process published in the surprise billing interim final rule issued last September.
The departments of Health and Human Services, Labor, and the Treasury officially revised the IDR process in August. At the time, CMS referenced the court decision, saying it will "remove the provisions that the District Court vacated." Now IDR entities may weigh qualified payment amounts and other factors equally in making their decisions.
This is still unjust, the TMA says, and major medical associations are showing their support for the TMA's newest filing.
The American College of Emergency Physicians (ACEP), American College of Radiology® (ACR), and American Society of Anesthesiologists (ASA) filed a joint amicus brief with the Texas court in support of the TMA. The American Hospital Association (AHA) and American Medical Association (AMA) also joined forces and filed a similar amicus brief.
According to the ACEP, ACR, and ASA, the groups will monitor the newest TMA suit and stand ready to challenge the final rule in the Northern District of Illinois if necessary.
"Many practices, reeling from COVID-19's economic impact, cannot withstand this insurer multi-edged profit grab and may be dropped from networks. These insurer restrictions impact all care (not just out-of-network care), including cancer screenings, which plummeted during the pandemic and may yet lead to more cancer deaths," the ACEP, ACR, and ASA said in a press release.
The AHA and AMA declared a similar mindset.
"Based on their own apparent policy preferences, the Departments continue to add atextual requirements to Congress' simple framework," AHA and AMA wrote.
"Indeed, six months after this Court definitively interpreted the No Surprises Act, the Departments promulgated a Final Rule with numerous extra-statutory requirements that will interfere with a balanced consideration of Congress' mandated factors and put a thumb on the scale in favor of the QPA," the AHA and AMA said in its brief to the court.
"The severe rate cuts enabled by the Departments' insurer-friendly regulations threaten the viability of physician practices and the scope of medical services nationwide. Ultimately, the victims will be the patients who lose ready access to care."
The Texas case again solely impacts the IDR process to determine provider reimbursement for out-of-network care. The suit does not impact No Surprises Act patient protections or raise patient out-of-pocket costs.
The AHA and AMA strongly believe that no patient should fear receiving a surprise medical bill and that patients should be kept out of the middle of any billing disputes between providers and commercial health insurance companies.
The groups say they want to see the law’s core patient protections move forward and seek only to bring the regulations in line with the law.
While the chilly October rain falls over Boston, prominent revenue cycle leaders are cozying up inside the Boston Park Plaza hotel to discuss revenue cycle technology optimization.
Automation and technology are obviously top of mind for the executives attending this week's HealthLeaders RevTech Exchange. As regulatory burdens and workforce shortages put strains on their revenue cycles, leaders agree technology is where they need to be investing.
"When we think of revenue cycle technology, we need to think about technology in ways that don't just push more work onto other staff, but ways to really automate and streamline our processes," Michael Finley, director of revenue cycle at Bellin health, said during the event kickoff.
Finley is just one of the many revenue cycle executives attending this event designed to bring leaders together to discuss revenue cycle technology strategy.
In a poll conducted by HealthLeaders at the beginning of the event, 47% of the group said their revenue cycle operations are fully automated, while 83% said revenue cycle technology transformation is an absolute and immediate need for their organization.
Today's event included a dynamic workshop led by CIO and digital health futurist Ed Marx where he discussed how revenue cycle teams are now looked upon to raise patient satisfaction while also increasing efficiency.
Discussion sessions were also held that focused on robust conversations about automating front-end processes, including prior authorizations and good-faith estimates, and using technology to help relieve staffing shortages.
Stay-tuned for more coverage of this event which will include “ideas presentations” from prominent leaders such as Lynn Ansely, vice president of revenue cycle management at the Moffitt Cancer Center, and Jennifer Johnson, executive director of utilization management at AdventHealth.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
24a9.jpg?itok=QA2DdW4I)
