Enforcement for certain good faith estimate (GFE) provisions are being delayed.
CMS recently gave revenue cycle leaders an extension of its enforcement discretion on the convening provider requirements that are part of the GFE in its newest FAQ.
Under the law, healthcare organizations need to give patients who don't have certain types of healthcare coverage—or those who are paying out of pocket—an estimate of their bill before services are provided.
Not only do these GFEs need to be created, but they also need to be created quickly as patients have the right to receive a GFE for the total expected cost of items and services as soon as they schedule an appointment (the items can include costs of tests, drugs, equipment, hospital fees, and more).
The GFEs also need to be accurate since patients can dispute final medical bills if the charges are at least $400 more than what was presented on the GFE.
On top of all of this, the rule also includes a "convening provider" requirement.
This means GFEs need to cover not only the provider’s own services, but those of downstream providers expected to be needed to complete treatment.
This specific requirement has been an area of contention for hospitals and medical groups. In fact, the MGMA recently pleaded with CMS to extend the enforcement discretion for the convening provider/facility and co-provider/facility provisions for GFEs.
At the time the MGMA said enforcement discretion should continue until appropriate standards have been developed, tested, and implemented by group practices.
According to the recently published new guidance, CMS said HHS is extending enforcement discretion, pending future rulemaking, for situations where GFEs for uninsured or self-pay individuals do not include expected charges from coproviders or co-facilities until further notice.
Enforcement of this part of the No Surprises Act requirement was expected to start January 1, 2023.
WEDI recently applauded this guidance and Charles Stellar, WEDI president and CEO, went on to say that "the industry continues to make progress in developing data interchange standards to support the requirements of the No Surprises Act. We commend HHS for extending the enforcement discretion period and averting significant administrative burdens on providers. The HHS action today grants the time necessary to develop cost efficient solutions and implement supporting regulations."
HealthLeaders' regulatory round up series highlights five essential governing updates that cover every aspect of the revenue cycle that leaders need to know. Check back in each month for more updates.
The revenue cycle is complex, detailed, and always changing, so staying on top of regulatory updates and latest best practices requires revenue cycle leaders' constant attention in this ever-changing industry.
In this revenue cycle regulatory roundup, there were an ample number of updates published by CMS and the OIG in November, including the OPPS and physician fee schedule final rules.
Here are the five updates you need to know.
Medicare providers did not always comply with federal requirements when billing for advance care planning.
The OIG published a review regarding whether Medicare providers who received payments for advance care planning (ACP) services in an office setting complied with federal requirements.
The OIG found that 466 of the 691 ACP services did not comply with federal requirements. Issues included providers claiming that they did not know that the time for ACP services had to be distinguished between time spent discussing ACP and time spent on concurrent services. Some providers said they were unaware there was a time requirement.
The OIG said that, based on this sample, it estimates that Medicare providers received approximately $42.3 million in payments for ACP services that did not comply with federal requirements.
The OIG also noted that it found some claims where 15 or more ACP services were received during the 12-month audit period, and while that did not reflect noncompliance, it did not align with CMS guidance in an FAQ suggesting that ACP services billed multiple times for a beneficiary should include a documented change in the beneficiary’s health status, end-of-life care wishes, or both.
The OIG recommends CMS educate providers on documentation and time requirements for ACP services, instruct the MACs to recoup the money paid in error for claims in the sample, and instruct the MACs to notify providers so they can identify, report, and return similar overpayments.
The OIG also recommends CMS establish requirements that address when it is appropriate to provide multiple ACP services for a single beneficiary and how these services should be documented to support the need for multiple ACP services. CMS concurred with all but the fourth recommendation.
Medicare improperly paid physicians for co-surgery and assistant-at-surgery services that were billed without the appropriate payment modifiers.
The OIG published another noteworthy review in November, this one focused on whether Part B payments to physicians for potential co-surgery procedures complied with federal requirements.
The OIG found that 69 of the 100 statistically sampled services did not comply with requirements. This included 49 services incorrectly billed without the co-surgery modifier, 14 incorrectly billed without an assistant-at-surgery modifier, and six that were incorrectly billed as duplicate services.
The OIG also reviewed 127 corresponding services and found that 62 of those did not comply with federal requirements, as 33 were incorrectly billed without the co-surgery modifier, 16 were incorrectly billed without an assistant-at-surgery modifier, and 13 were incorrectly billed as duplicate services. The OIG determined that these errors resulted in $56,016 in overpayments.
The OIG recommends CMS recover the portion of the $56,016 in Part B overpayments within the claim reopening period, instruct Medicare providers to identify, return, and report any similar overpayments, strengthen its system control to detect and prevent improper payments for these types of services, and update Medicare requirements and corresponding educational material to improve providers’ understanding of the Part B billing requirements for co-surgery procedures.
CMS concurred with these recommendations.
Medicare began its enrollment of rural emergency hospitals.
CMS published a transmittal regarding the addition of information about rural emergency hospitals (REH) enrollment applications to the manual.
This information walks through the process for a critical-access hospital or rural hospital wishing to convert to an REH and provides instructions for the contractors on processing these enrollment applications. The transmittal was originally published internally on September 15, but it is no longer sensitive information and is now posted for the public.
The 2023 Medicare physician fee schedule final rule was released.
CMS published the 2023 Medicare physician fee schedule final rule. The rule finalized a decrease in the conversion factor down from $34.61 in 2022 to $33.06 in 2023 (two cents less than the $33.08 listed in the proposed rule). Other policies finalized in the rule include:
Adopting coding/documentation changes for E/M visits (including hospital inpatient, observation, emergency department, and more) that align with changes made by the AMA CPT Editorial Panel for January 1, 2023. This includes eliminated use of history and exam to determine code level, revised interpretive guidelines for levels of medical decision-making, and the choice of medical decision-making or time in determining code level.
Delaying the split-shared visits policy until 2024. This policy will change the definition of the substantive portion as more than half the total time.
Extending the time that telehealth services are temporarily included on the telehealth services list during the PHE but are not included on a Category I, II, or III basis for 151 days following the end of the PHE. Providers should continue to report telehealth services with modifier 95 during the PHE, but audio-only services should be reported with modifier 93 effective January 1, 2023.
Making an exception to direct supervision requirements under “incident to” regulations allowing behavioral health services provided under general supervision of a physician or non-physician practitioner (NPP) when the services or supplies are provided by auxiliary personnel incident to the services of a physician or NPP.
Codifying the reporting of modifier -JW for reporting wastage for all separately payable drugs with wastage from single use vials or single use packages effective January 1, 2023, and the reporting of modifier -JZ for reporting single use vials or packages with no discarded amount effective July 1, 2023, with editing beginning October 1, 2023. Other issues were clarified in commentary.
Codifying changes to coverage of certain dental care inextricably linked to and substantially related and integral to the clinical success of covered medical services.
The rule is effective January 1, 2023.
The outpatient prospective payment system (OPPS) final rule was also released.
CMS published the 2023 OPPS final rule. The rule finalizes updates to both OPPS and ambulatory surgical center (ASC) PPS payment rates by 3.8% for 2023, significantly higher than the proposed 2.7% increase in payment rates.
Policies finalized in the rule include:
340B payment rate updates.
Removing 11 services from the inpatient-only list, adding eight services to the inpatient-only list, and adding four services to the ASC covered procedures list.
Continuing coverage for behavioral health services furnished remotely by hospital staff to beneficiaries in their homes beyond the end of the public health emergency (PHE) as long as the beneficiary receives an in-person service within six months prior to the first remote service and once every 12 months following that.
Adding facet joint injections and nerve destruction as an additional service that would require prior authorization, effective July 1, 2023, rather than the proposed date of March.
Approving four of the eight applications for device pass-through payments for CY 2023.
Finalizing changes to the supervision requirements for diagnostic services to allow non-physician practitioners to supervise diagnostic services within their scope of practice, similar to services provided under the physician fee schedule.
CMS is implementing a requirement from the Consolidated Appropriations Act of 2021 to establish REH as a new provider type. Critical access hospitals and certain rural hospitals may choose to convert to an REH and would be allowed to provide emergency department services, observation care, and certain outpatient medical and health services.
Discontinuing its reconciliation process was an easy decision for one revenue cycle leader at UC Davis Health.
2022 has been a financial struggle for most hospitals, and revenue cycle leaders have been tasked with helping to improve the bottom line. It’s no secret that one of the areas most closely tied to reimbursement is the middle revenue cycle.
When it comes to streamlining the middle revenue cycle to increase productivity and help that bottom line, one area leaders look to is the reconciliation process.
While some leaders believe the CDI and coding reconciliation process is an important step in proper documentation and denials management, other leaders have said the time spent reviewing the mismatches is not only bad for productivity, but team moral as well.
Tami McMasters Gomez, the director of coding and CDI services for UC Davis Health, made the decision to do away with its reconciliation process, and since she was armed with data, gathering support from other leaders was easy as well.
HealthLeaders: Did you find it easy to get other revenue cycle leaders on board with your decision to change this process up?
Tammy McMasters Gomez: I did. Once I was able to demonstrate the high accuracy rates of our coding team and show that I believed this process could be done more efficiently, there was a lot of buy in from our C-suite. By changing the way we did it, we had a lot of benefits.
HL: I know that we chatted about the 33% increase in productivity, but what other positive outcomes have you seen since changing this process?
McMasters Gomez: I will say that it allows individuals who are seeking education or feedback on their performance a chance at a daily interaction with a team member who is very direct and has an education background.
Previously, when we left it up to the coder and the CDI specialist to go back and forth and provide education to each other on why there was a DRG mismatch, it wasn’t very helpful because coders and CDI specialists don't necessarily speak the same language.
I think this new process has provided that direct feedback that’s easily digestible and referenced by material that is specific to that person. I think it's created a better understanding from the team because some of the feedback I got was: “I don't understand what the coders are saying,” or the coder would say “we don't code based off a clinical findings, we code based on documentation.” There was a lot of that back and forth.
Now all of that is done in a nice write-up format and presented back to the team, and in my opinion, it’s irrefutable because there's evidence, documentation, and all of the coding or CDI resources are presented back to the teams. It's created a great educational opportunity. And again, the CDI teams can now spend more time doing clinical reviews.
Also, that productivity piece has allowed us to spend more time looking at some of the more complex things. This change didn’t just increase team productivity, but it increased the integrity of the reviews and the type of reviews that we're doing. As the landscape is kind of moving more towards quality outcomes, we're able to better measure that performance.
HL: When taking on such a large endeavor like reworking an entire reconciliation process, revenue cycle leaders can be very hesitant. Can you give them any advice on moving forward and taking those first steps towards something like this? What can they say to their CDI or coding directors to get them on board?
McMasters Gomez: I think I would start by really looking at the time being spent on reconciliation and the impact it has on the teams.
And make sure you have a strong coding team first—it really does start with high coding accuracy rates. If you have a coding team that's not strong, the process you have in place may work.
That's how I think it evolved for us—we already had such a high accuracy rate, it didn't really make sense to have a reconciliation process in place where the CDI specialists were questioning the coders, because 99% of the time the coders were right already.
That’s why for us it was about making sure that we were more efficient in how this process was conducted. It's about efficiency.
I would tell revenue cycle leaders to demonstrate how the process is currently working when looking for buy-in on a change like this. Is it efficient? What's the time being spent on it? And then ask about those coding accuracy rates. If you have a very high coding accuracy rate and your coders are accurate 99.9% of the time during that DRG mismatch review, does it make sense to continue this reconciliation process?
The Director of Coding and CDI Services for UC Davis Health chats with Healthleaders about its leap of faith in discontinuing its reconciliation process.
At the heart of the revenue cycle are the CDI and coding teams, which is why revenue cycle leaders tend to focus here first when looking to rework processes, improve productivity, and increase the bottom line.
When it comes to streamlining the middle revenue cycle, one area leaders look to is the CDI reconciliation process.
Traditionally, a CDI and coding reconciliation process consists of a CDI specialist reviewing a chart, assigning a working diagnosis-related group (DRG), and occasionally determining a set of diagnosis and procedure codes proactively to help create queries, quality reviews, and more—all before the patient has even left the building.
Once that patient gets discharged, the coding teams report the case based on the documentation in the medical record. And, if the MS-DRGs and/or codes don't match what the CDI team chose, the chart could be passed back to the CDI team to identify the mismatch.
While some leaders believe this reconciliation process is an important step in proper documentation and denials management, other leaders have said the time spent reviewing the mismatches is not only bad for productivity, but team moral as well.
To discuss this further, HealthLeaders caught up with Tami McMasters Gomez, the director of coding and CDI services for UC Davis Health, about how she recently did away with her entire CDI and coding reconciliation process and found positive results from doing so.
This is part one of a two-part series.
HealthLeaders: We spoke earlier this year about the technology that UC Davis has been implementing in the middle revenue cycle. And at the time you mentioned to me about your organization's discontinued CDI reconciliation process. Since it seems to be the opposite of what a lot of revenue cycle leaders look to do, I was so eager to chat with you about it.
Revenue cycle leaders obviously know every aspect of the revenue cycle, but depending on an organization’s size, they may not be as in the weeds with CDI and coding as their directors are. So, we are chatting about this topic today because this change that you made in your department increased productivity by 33% and that can have a huge impact on the revenue cycle.
To start us off, can you give revenue cycle leaders a brief overview of what your CDI and coding reconciliation process looked like?
McMasters Gomez: Before discontinuation, if the teams’ DRGs didn’t match, there was a process where the coder would pass it back to the CDI specialist in a work-cue-type environment and say, “my DRG doesn't match yours, let's figure out why.” The CDI team would then spend sometimes 30 or 40 minutes trying to figure out why their DRG didn't match the coders.
In most cases, the CDI team does not consist of seasoned coders: they're clinical reviewers. And the mismatch could have been from an obscure coding guideline or a seventh character in a procedure code that the CDI specialist just wasn't aware of. It just didn't feel like it was very productive to have this process in place.
This process also created a low team moral. There was this back and forth between the teams and they were questioning me and asking, “why are we doing this?” It really felt like there could be a better way at UC Davis.
That's kind of what set this in motion for me. I needed to figure out how we could make the process more efficient and why this process was creating more problems in the unit and less team engagement.
Tami McMasters Gomez, director of coding and CDI services for UC Davis Health. Photo courtesy of HealthLeaders.
HL: What happened to make you see that discontinuing this entire process was the right move? And what was your process in implementing this change?
McMasters Gomez: As I mentioned, my wheels started turning about why this process was so adversarial and why the teams were going back and forth. I also began wondering why I was holding the CDI team to a coding standard when they're not coders.
We actually had two external audits done back-to-back in 2019 and 2020 to gauge our coding accuracy rates. I already knew we had a strong coding team, but the third-party auditors determined that we have a 99.9% coding accuracy rate.
I knew there was one benefit to having this reconciliation process, and that was the education the teams received from investigating or learning about why their DRGs didn't match when we have such high coding accuracy rates. And then I thought, well, “What can I do to take this process outside of these teams so that they could spend time doing what they do, coding and clinical reviews?”
That’s when I created a back-end process where I have clinical reviewers that get a daily report that shows all of the DRG mismatches. That review, which is done by both a high-level coding analyst/auditor with CDI credentials and a CDI lead, do the reviews and provide individual feedback to either the coder or the CDI specialist on why there was a difference in the DRG.
That review is done retrospectively prebill, and the individual feedback is provided to the team in real time prior to completing the case with the supporting documentation on why there was a DRG mismatch.
We also look for trends. If everybody's missing the boat on this one area, then we provide a much broader education or scope. But we really did a lot of looking at data and leveraging reports. And when there are coding errors or missed opportunities discovered, there's direct feedback daily to the coders so they're still getting that education.
We found that after implementing this change, CDI productivity increased more than it did the coders by anywhere between 25% to 33%. This new process really lets the coders be coders and the CDI specialists have more time to perform those clinical reviews and touch more cases.
And another added benefit was team morale. It really did just completely change the morale regarding the interaction between the coders and the CDI.
Revenue cycle leaders at these prominent organizations chatted with HealthLeaders about how they delt with the No Surprises Act implementation this year.
It has been a while since a regulation has shaken the revenue cycle as much as the No Surprises Act has.
As CMS continues to make changes to the various aspects of the No Surprises Act, the struggle to implement changes and adjust processes is far from over.
One of our top stories from 2022 detailed how organizations worked to implement and keep up with changes surrounding the No Surprises Act. As regulations continue to evolve into 2023, their stories are as pertinent as ever.
Karen Kennedy, director, revenue cycle, Cleveland Clinic, Ohio and Florida:
"Our planning and preparation for the No Surprises Act (NSA) was led by a cross-functional team including high-functioning caregivers from IT, legal, patient access, billing, self-pay follow-up, and education.
Members of this team meet weekly to create an overall strategy and manageable ongoing process that met all of the additional requirements of the NSA.
Although implementation was complex and resource intensive, Cleveland Clinic fully supports the legislation to protect patients from surprise billing."
Sarah Ginnetti, associate vice president of revenue cycle at UConn Health, Connecticut:
"As a result of preparing for that regulation, we did stand up another cross-functional team in the organization. We found a way to develop some workflows within Epic [and] identify the right team members to assign to some of this work in order to manage and respond to the No Surprises Act.
I think we actually have a pretty good process in place. It is very manual and that's the one thing I don't like about it. But we right now don't have the infrastructure set up around it to make it a more automated process. However, that is part of our roadmap going forward that's tied to the patient experience. [That will include] building out our estimate platform.
For all intents and purposes, we are, I would say, 90-plus percent compliant, and were as of January 1."
2022 brought many challenges for revenue cycle leaders, and COVID-19 reporting was no exception.
This past year was trying for hospitals for many reasons. From staffing shortages to financial challenges, revenue cycle leaders faced many trials in 2022.
One thing that is still top of mind for leaders though, is COVID-19 reporting. While COVID-19 might seem like old news at this point, its reporting and subsequent reimbursement is still of utmost importance. Because coding occurs mid-cycle, it provides an opportunity to catch errors introduced earlier in the process, as well as preventing similar errors in the future.
Staying abreast of these regulatory coding updates is important for revenue cycle leaders as coding—and its completeness and accuracy—has a profound impact on an organization's bottom line.
Its importance was proven as our article on COVID-19 reporting hit one of the top spots for 2022. Here’s what you—and your middle revenue cycle—still need to know about reporting COVID-19 ICD-10-CM diagnosis codes.
Thanks to various code updates since the beginning of the pandemic, there is now a long list of COVID-19 diagnosis codes.
Here are the ICD-10-CM codes that specifically represent COVID-19:
J12.82, pneumonia due to coronavirus disease 2019
U07.1, COVID-19
U09.9, post COVID-19 condition, unspecified
Z11.52, encounter for screening for COVID-19
Z20.822, contact with and (suspected) exposure to COVID-19
Z28.310, unvaccinated for COVID-19
Z28.311, partially vaccinated for COVID-19
Z86.16, personal history of COVID-19
Make sure your teams keep in mind that specific documentation isn’t necessarily needed for COVID-19 code assignment.
The 2022 ICD-10-CM Official Guidelines for Coding and Reporting state that physicians do not have to specifically document “COVID-19” for code U07.1 (COVID-19) to be assigned.
Per ICD-10-CM guidelines, code only a confirmed diagnosis of COVID-19 as documented by the provider, or documentation of a positive COVID-19 test result.
This guideline allows U07.1 to be assigned if the documentation includes a positive COVID-19 laboratory result.
Coding Clinic, Second Quarter 2020, provided additional clarification on this, too. It said that the provider does not need to explicitly link the test result to the respiratory condition, the positive test results can be coded as confirmed COVID-19 cases as long as the test result itself is part of the medical record.
“As stated in the coding guidelines for COVID-19 infections that went into effect on April 1, code U07.1 may be assigned based on results of a positive test as well as when COVID-19 is documented by the provider. Please note that this advice is limited to cases related to COVID-19 and not the coding of other laboratory tests,” it said.
Never assume that COVID-19 was present on admission.
If a physician doesn’t specifically state a patient acquired the COVID-19 infection in your hospital, it is still not appropriate for your teams to assume it was present on admission. In fact, per the ICD-10-CM guidelines, a provider should be queried regarding issues related to the linking of signs/symptoms, timing of test results, and the timing of the findings.
There are COVID-19 vaccine codes for all hospital types: both inpatient and outpatient.
ICD-10-CM diagnosis codes for vaccine status are for all patient types. The vaccine CPT® codes are for outpatient reporting. There are also ICD-10-PCS codes for inpatient reporting of COVID-19 vaccines.
With attention on population health and quality initiatives, rev cycle leaders have turned their focus on how capturing SDOH impacts patients.
Social determinants of health (SDOH) are social factors, such as homelessness, illiteracy, a history of childhood trauma, and joblessness or underemployment, that can affect a person’s health.
With increasing attention on population health and quality initiatives, organizations have turned their focus on SDOH and how capturing those ICD-10-CM codes impacts their patient population and their success in caring for that population. Experts have been urging hospitals to capture the codes for SDOH for years, but the message still doesn’t appear to be resonating.
Because of staffing shortages and financial losses as the result of COVID-19, revenue cycle leaders such as coding and CDI directors have been focusing their efforts elsewhere, especially since the capture of SDOH doesn't have an impact on reimbursement.
Adoption of SDOH capture is still only 1.59%, Tiffany Ferguson, LMSW, CMAC, ACM, CEO of Phoenix Medical Management, told the Revenue Cycle Advisor. The time is now for organizations to ensure that these codes are captured, she says.
The main reasons why hospitals aren’t capturing SDOH codes aren’t difficult to understand—there is no reimbursement for them, and their capture is not required, says Ferguson. Organizations also need to focus on medical diagnoses.
“Thus, [SDOH codes are] always going to fall to the bottom of the list or off the list,” she says.
But, as organizations start to place more of an emphasis on patient experience and population health, revenue cycle leaders have started baking in SDOH capture to improve patient outcomes.
Current electronic health record (EHR) systems may contribute to the lack of capture as these systems are often not automated for these codes, and the information is not always easy to find in the record.
A Florida health system found the same to be true and has started putting SDOH right into the EHR problem list, where doctors can see and act on them.
Jennifer Goldman, DO, chief of Memorial Primary Care at the six-hospital Memorial Healthcare System, based in Hollywood, Florida, recently explained to HealthLeaders how it embedded SDOH right into the EHR and how it uses that information to improve patient outcomes.
HealthLeaders: A JAMIA report from 2021 found there is no consensus on which SDOH measures should be captured in the EHR. How do you decide which ones to add?
Goldman: That's an ongoing discussion in our system. We utilize Epic, which has a social determinants of health wheel, which is just a graphic representation of the varieties of determinants of health that somebody is dealing with. And the major challenge for us in our organization was to determine which ones we were going to prioritize and start with.
We don't know if all of them truly impact health equally, but we do know that there are three that are a priority not only for us, but for Medicaid. If we can do something about these, we can probably impact more in a person's health than if we address resources elsewhere. Those are food, housing, and transportation. Substance abuse is a huge social determinant of health, but we already have a process for that, where we already screen everybody for that when they come in. The three social determinants of health we focus on are traditionally outside the wheelhouse of any physician. Those are things that we just did not ask people.
HL: How do you capture the data about the need, and how do you match the need with the actual service?
Goldman: We utilize the Epic release social determinants of health wheel. And we ask first our health coaches, our nurse navigators, and in some cases our social workers to review these determinants for the patients that were on their high-risk panel, patients that have significant ER visits or who are ill with multiple different chronic conditions.
We focused first on that population. Case managers were asking some of those questions anyway, but they were asking them in a non-capturable, non-standardized way. We standardized the way that we were capturing that data so that we could run analytics on it and show that information in the EHR to physicians. If our providers don't know that the patient they're treating right now is homeless or doesn't have access to healthy food or doesn't have access to transportation, that would probably impact their decision-making in terms of what treatment they were going to prescribe for that person.
We built something called an alert or a best practice advisory, where if somebody screened positive for homelessness, food insecurity, or transportation need, that would pop up [in front of] the clinician. And we took that a step further, because sometimes pop-ups in the EHR are negatively looked at. I never wanted to have an empty best practice advisory, where the doctor would have to do five more clicks to document that in the EHR. We drop the code for that specific social determinant of health into the problem list and into what we call a visit diagnosis.
We also included documentation that the patient was going to be automatically sent to our care team for follow-up in terms of how to access resources. We did that by having an automated in-basket so that it didn't hinge on a physician or a nurse practitioner or PA remembering to involve a social worker. This would happen automatically. We work with our community resources, such as the Broward County Task Force on Homelessness, and many other housing resources, as well as transportation assistance. With food, we work with multiple local food banks. We do direct connections with people we call and get those resources for them, instead of just handing a piece of paper to a patient.
HL: When did these processes go live, and what are the outcomes like so far?
Goldman: These alerts went live six months ago, and the outcomes have been significant. We've tripled the number of ICD-10 codes in the EHR for social determinants of health. That means that our physicians are documenting three times more on homelessness and food insecurity and transportation than they were previously. So we know that it's being captured.
We know that interventions are being done because we can track that as well. And we know that all those social determinants of health that we're screening for, all those patients ended up getting a referral to the care team and the care team contacted them and gave them the resources that they need. We're in the process of measuring outcomes, which ultimately is the most important thing. We're looking at data for no-show rates for appointments.
HHS released a proposed rule outlining changes it wishes to make to the 340B administrative dispute resolution process.
HHS issued a new proposed rule revising the 2020 final rule that established the 340B administrative dispute resolution (ADR) process to better align with requirements found within the Affordable Care Act.
For background, the 340B program requires drug manufacturers to provide outpatient drugs to eligible healthcare organizations and other covered entities at significantly reduced prices. The ADR process is an administrative process designed to assist these organizations and manufacturers in resolving disputes regarding overcharging, duplicate discounts, or diversion.
340B payments are a lifeline for some organizations, making the ADR process that much more important as hospitals need to ensure fair and accurate payment.
"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.
According to the proposed rule, there are a few major proposed changes to the ADR process:
Establish a more conventional administrative process for disputes and move away from the current “trial-like” proceedings
Include 340B program subject matter experts from the Health Resources and Services Administration’s Office of Pharmacy Affairs on the ADR panel
Align the ADR process to statutory provisions on overcharges, duplicate discounts, and diversion
Offer a reconsideration process for parties dissatisfied with the 340B ADR panel decision
Historically, HHS has encouraged manufacturers and covered entities to work with each other to attempt to resolve disputes in good faith, it said in the proposed rule. The ADR process is not intended to replace these good faith efforts, HHS says, and the ADR process should be considered only when good faith efforts to resolve disputes have been exhausted and failed.
This proposed rule comes on the heels of a troublesome year for the 340B program.
In the recent 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 that unanimous Supreme Court decision.
Hospitals and health systems can send comments on the rule to HHS by January 30, 2023.
As financial pressures put a strain on revenue cycle operations, many leaders are looking toward their revenue integrity departments for help protecting their bottom line.
As the revenue cycle continues to be an area of focus for organizations, revenue cycle leaders have turned to streamlining (and even creating) revenue integrity departments to reduce the risk of noncompliance, optimize payment, and minimize the expense of fixing problems downstream with claim edits.
Healthcare organizations are expected to end the year in the red, so now is the time to optimize all revenue cycle functions.
Although the complexity of revenue integrity functions can be daunting to measure, the relative newness of many revenue integrity departments is another reason productivity metrics might not be used or streamlined yet, Kim Yelton, RHIA, CCS, CDIP, CHRI, revenue integrity director at WakeMed Health and Hospitals in Raleigh, North Carolina, told NAHRI.
When a revenue integrity department is first established, the primary focus is often dealing with immediate charging, billing, or compliance issues and defining the new department’s responsibilities.
Read on for more advice from NAHRI on productivity measures.
As a revenue integrity program becomes more established and clarifies its functions, revenue cycle leaders switch their attention to metrics for process improvement, and that’s when productivity starts to come into focus, Yelton says. The same metrics that are analyzed for process improvement, such as how to reduce touches on accounts, manage work queues, or reduce denials, can yield data for productivity metrics.
The systems and data that revenue integrity departments already use are valuable sources of productivity information, agrees Paula Twiss, MBA, CRCS-P, CRCS-I, supervisor of revenue integrity at Monument Health in Rapid City, South Dakota. Twiss has been experimenting with different data sets pulled from Epic to develop productivity metrics for implementation at the start of the next fiscal year.
Currently, Twiss uses a productivity report in Epic that monitors her teams’ activity in accounts. She runs the report weekly and reports on it monthly during one-on-one meetings with her team. However, the report is only as good as the data Epic captures, she says. In addition, her team works on a variety of projects and meetings outside of Epic. To fill those gaps, Twiss created a document that’s updated during weekly huddles and covers the previous week’s work.
“Every Monday we spend an hour with the team and fill out this huddle document that goes through what their goals were for the week, what work they’ve done, what meetings they were at, what work queues they were able to get into and complete, and the status of those,” Twiss told NAHRI.
To fill out potential productivity metrics, consider what already exists for at least some revenue integrity functions. For example, if revenue integrity staff are involved in denials management, some existing metrics, such as denial rate or completed appeals, can demonstrate productivity, according to Twiss.
Ideally, as much productivity data as possible should be gathered from existing systems, Yelton says. Although currently some manual data collection is unavoidable, best practice should aim toward finding ways to improve data collection through systems to reduce the need for manual collection.
An expert shares tips for revenue cycle leaders looking to streamline automation.
Revenue cycle leaders have been tasked with helping to tighten the belt of hospitals as rising expenses continue to wreak havoc on hospitals and health systems across the country.
When looking to cut costs and streamline processes, many revenue cycle leaders are turning to automating mundane administrative tasks. For years studies have shown that a large amount of health expenditures go toward administrative costs. Ranging from billing and coding to insurance, these costs can negatively impact an organization’s bottom line.
From patient access to account resolution, automating routine processes gives providers the opportunity they need to cut down on administrative costs. To learn more, HealthLeaders touched base with Teri Schmidt, vice president of consulting and business development at SYNERGEN Health, to see how revenue cycle leaders can best leverage automation and cut these costs.
HealthLeaders: In which area of the revenue cycle are leaders seeing the most challenges, and how can these challenges be remedied with automation?
Teri Schmidt: One of the biggest challenges that revenue cycle leaders face is a lack of resources to manage workloads. We still face a nationwide workforce shortage in our industry, the same issue we have been plagued with since even before the COVID-19 outbreak. Whatever the reason for leaving may be, this exodus has put a massive strain on healthcare organizations revenue cycles. By automating workflows within the revenue cycle, we can streamline repetitive manual efforts that otherwise would have inundated the staff. By automating tasks such as claim review, claim follow up, and denial management, healthcare organizations enable staff to focus on more important, qualitative tasks.
The other most impactful challenge revenue cycle leaders face today is an increase in aged receivables. With greater financial responsibility being placed on the patient, healthcare organizations are seeing the average number of days it takes to collect payments due increase. Automated solutions help implement a patient-centric outreach strategy to assist patients in making informed cost decisions pre-visit and simplify post-care billing processes. This reduces the chances of surprise billing as well as an increase in aged receivables.
HealthLeaders: How can a streamlined revenue cycle strategy improve work efficiency for an organization?
Schmidt: We’re seeing more and more health organizations exploring and adopting automation solutions to drive their revenue cycle management transformation. These innovations can help them improve the efficiency and effectiveness of their operations by combining the power of machine learning and robotic process automation. Ultimately, by digitizing and automating their most repetitive end-to-end processes and functions, organizations are more empowered to drive value to the bottom-line while scaling resources to focus on complex, value-added activities. Automation powered by artificial intelligence and machine learning can even predict, prevent, and detect denials before the claims are submitted to the payer.
HealthLeaders: How can an automated revenue cycle help providers cut down on administrative costs?
Schmidt: Healthcare organizations can reduce their costs by investing in the right technology. From billing inefficiencies and payer-provider alignment to an increasing demand for resources, and inefficient manual workflows, automated revenue cycle tools can help address the plethora of issues that add to the cost to collect.
For example, when implementing robotic process automation into the appeals process, providers could have an increase in revenue and minimized administrative burden. Time consuming tasks preparing for the appeal and providing supporting documentation can be completed quickly with an increased level of accuracy by an RPA bot.
HealthLeaders: Why has automation been essential to organizations’ revenue cycles and how has it helped drive proper reimbursement?
Schmidt: Timely payments are the lifeblood to keeping your practice running. The revenue cycle process is complex with many opportunities for breakdowns in efficiencies and revenue leakage across the life cycle of a claim. By managing revenue cycle processes through automated solutions, healthcare organizations can improve results across the back end while decreasing labor-intensive tasks.
For example, by implementing automated insurance eligibility checks, patients understand their financial liability before receiving care and work with the provider to set up financial plans. This promotes financial transparency and streamlines the reimbursement for the provider.
HealthLeaders: With the current financial state, what can revenue cycle leaders expect in the coming year?
Schmidt: We have witnessed some of the toughest years the American health system has ever faced, but we still aren’t out of the shadow of the pandemic. Healthcare organizations have still not returned to pre-pandemic levels, and the coming year will likely feature trying economic battles as we approach a potential recession. While healthcare systems have witnessed an increase in patient volume, most likely due to elective procedures and COVID-19 surges, margin fluctuations denote a lack of stability.
Revenue cycle leaders can also expect a continued rise in expenses and administrative costs paired with a decline in staffing numbers to force health systems to find new alternatives. For example, introducing new hybrid staffing models could be a potential solution.
HealthLeaders: What tips do you have for revenue cycle leaders who are unsure if they should implement new technology or solutions?
Schmidt: To them, I have to say that transitioning and adopting any new technologies will always be daunting. It also goes without saying that choosing the right partner to streamline revenue cycle management is not easy, and any healthcare organization doing so should properly vet any potential candidate. The biggest tip I have is always to ask questions and always consider your team. From revenue cycle expertise to ease of integration, finding the right revenue cycle partner requires you asking the right questions about what’s best for your organization.
Deploying automation to broken workflows will not always produce an improved result. Some workflows just need re-engineered processes. It’s important to find an experienced revenue cycle partner that can identify where automation can truly drive an improved result. Some questions to keep in mind:
Do I know where the breakdowns are currently across revenue cycle?
