Sarah Hartwig, patient access officer at Avera Health, discusses how the organization is improving reimbursement and advancing the patient experience through automation.
The complexity of medical reimbursement not only creates a poor patient financial experience, but it also drives up hidden costs for organizations.
Automating certain processes within the revenue cycle can protect patients from surprise medical bills and allow staff to spend more time on meaningful work to improve the patient financial experience, but it’s not a one-size-fits-all endeavor.
Avera Health, an integrated health system based in Sioux Falls, South Dakota, serves patients through 37 hospitals, 215 primary and specialty care clinics, 40 senior living facilities, sports and wellness facilities, and more. In order to improve its revenue cycle processes across its complex system and create a positive patient financial experience, Avera Health realized automation was key.
The patient access officer at Avera Health, Sarah Hartwig MBA, MSHS, focuses on front-end revenue cycle operations and recently shared with HealthLeaders her experience in helping to implement automation solutions in this area of the revenue cycle.
HealthLeaders: Why has automation been essential to your organizations’ revenue cycle?
Hartwig: I think we all know that medical reimbursement is complex. When I started out in healthcare, we would talk about what a dynamic environment it is, and that was 20 years ago. And here we are now—even more dynamic and more complex.
Because of the complexity—from government regulations to payer expectations—it really makes automation even more important and integral to the holistic view of our strategies and revenue cycle. Automation also helps us better leverage our human resources. If we can offload those redundant and elementary tasks, it actually helps make those human efforts more meaningful.
We've noticed the need to unify that approach in the middle and back-end workflows, too. And that automation continuum allows us to have that perspective.
HL: What are key factors organizations should consider in selecting and implementing technology solutions for the revenue cycle?
Hartwig: For us, it's been about maintaining a focus on the patient. During the pandemic, we had to quickly change and shift to adopt new ways and new strategies of doing our work.
But, as we take more of a long-term focus, it really is about maintaining that focus on the patient while considering the needs of multiple stakeholders.
Another factor is interoperability. There are so many potential solutions out there. What we've found is that you need to focus on the core solution for your revenue cycle, build off of that, and then put the focus on interoperability so that it works in the day-to-day. Creating that interoperability will only better reimbursement and the patient experience.
Another consideration for us, again, is evaluating the long-term automation goals.
We feel pretty reactive after dealing with a lot of the changes in the past couple of years. It feels like we've had to quickly change and move. Now that we can breathe a little more, we can take a step back and really look at our long-term goals for these solutions, all while keeping the patient at the center.
One of our long-term goals is maintaining transparency. So, anytime we're selecting a tool for automation, we like to consider what information the patient, care team, and folks supporting the backend process will all see through this tool. This is important to us because we want to make sure there's a level of transparency for everyone.
Also, any automation tool that we're looking for, for example if we're truly leveraging the patient to self-serve, our team needs to consider building quality factors so that it doesn't take any type of rework from our revenue cycle staff.
And lastly, I'll just mention the vendor selection process. For us it is more about building partnerships. I'm building relationships and working more holistically with those partnerships that will take us to and through the long-term solutions that we are looking for.
HL: What are some of the broader trends that have driven adoptions of automation solutions?
Hartwig: We know hospital costs are increasing and reimbursement is not necessarily improving, so our margins are thinning. That’s why it’s so important that adoption of technology truly leverages and positively impacts our costs for operation.
For us, we continue to shift the focus from back-end workflows and try to alleviate and prevent some of those time-consuming tasks (like collections) by utilizing the front end of the revenue cycle. Automation in the front end is much more of a focus for us as it can prevent those errors that would burden the back-end staff.
We are also working to identify potential prior authorization and medical necessity denials early on in order to make sure those prevention factors are put in place. That has also led to more conversations and more inclusion of our care teams. I'm working to automate all of those financial clearance processes upfront so that we're engaging with patients immediately, so they know their out-of-pocket costs and what to expect moving forward. All of these factors will create a positive patient experience and have a positive impact on our bottom line.
Industry experts share advice for revenue cycle leaders on battling denials including closing gaps in the middle revenue cycle and understanding payer criteria.
Health systems have made avoiding and managing denials a top priority, but for many, their best efforts have yet to turn the tide. The quest to get ahead of denials and protect revenue has gained urgency as hospitals continue to cope with the financial impact of the COVID-19 pandemic.
In fact, hospitals and health systems are experiencing some of the worst margins since the beginning of the COVID-19 pandemic, putting 2022 on track to become the worst financial year for the healthcare sector since the crisis first started.
With budget cuts and staffing shortages putting pressure on revenue cycle leaders, denial management solutions can feel out of reach. But with knowledge, data analytics, and an organized strategy, organizations can address issues at their root and reduce denials.
The average rate of denials rose 23% from 2016 to 2020, according to a 2021 Change Healthcare report. Even after the onset of the pandemic, denials continued to rise—particularly in areas hardest hit by the first wave. Yet 86% of denials are avoidable, according to the report.
As previously reported by HealthLeaders, the denials rate has been steadily increasing of the last few years, and for one-third of hospitals, their average denials rate was more than 10%.
At the time of that study, the average national denials rate was between 6% and 13%, but many organizations were nearing what Harmony Healthcare called the denials "danger zone" of 10% of higher.
According to that survey, 33% of hospital executives reported average denial rates of more than 10% and 32% of respondents reported their top concern as coding.
In addition, pandemic-related changes in rules and staffing added fuel to the fire.
The rise in denials isn't surprising given the increasing complexity of reimbursement rules, Monica DuBois, RHIA, vice president of coding solution technology at DeliverHealth in Atlanta told HIMB.
"Everything blew up in 2020," DuBois says. "There were so many changing rules, and now we're just starting to see some of those denials come through."
So, what are some of the biggest denial pain points?
Experts agree that most of the current denial targets feature familiar coding diagnoses: sepsis, malnutrition, acute kidney injury, acute tubular necrosis, and respiratory diagnoses. Most of these diagnoses are based on clinical criteria, and there may be differences in the criteria used by providers, payers, and third-party auditors, Melissa Rodriguez, CCDS, CDIP, CCS, CCS-P, CHRI, CPMA, manager of clinical denial solutions at Enjoin told HIMB.
Payers are taking a harder look at any claim with a respiratory, sepsis, or COVID-19-related diagnosis. More than 25% of audits are related to these diagnoses, according to Dawn Crump, MA, SSBB, CHC, senior consultant for revenue cycle solutions with MRO Solutions in Norristown, Pennsylvania.
Working with your CDI and coding directors to educate staff and provide more education around these diagnoses will only improve an organizations reimbursement rate.
Also, organizations should still be keeping a close eye on COVID-19 denials, particularly from commercial payers.
Commercial payers might have specific coding guidance, for example, that differs from CMS'. If an organization doesn't take that into account and coders aren't trained on these payers' rules, denials will start to rack up, DuBois says.
Looking outside of the revenue cycle silo is important to maintaining a well-rounded department, so take a look at three recent stories pertaining the revenue cycle from other healthcare leaders.
3 ways CFOs are containing staffing costs while investing in the future
CFOs are getting creative when it comes to retaining talent, succession planning, and maintaining the overall financial health of their organizations.
"A number of repetitive tasks have been automated and that has created the need for a new technical workforce to manage that work," says Michele Cusack, SVP and CFO at Northwell Health in New Hyde Park, New York. "Our largest area of success with RPA has been in revenue cycle, but we're trying to replicate the success in other functional areas as well using various technology platforms to further optimize workflow and putting tools in place to mitigate the need for manual work efforts."
New technology, strategies improve occupational health management
Health systems are using digital health tools and the electronic health record (EHR) to not only monitor staff health and track compliance but give employees an avenue to manage their wellness and connect with supervisors.
Atrium Health Wake Forest Baptist, based in Winston-Salem, NC, is running its occupational health program through a custom-built electronic health platform developed through a partnership with Enterprise Health. The platform gives administrators insight into employee compliance and engagement rates, while streamlining the communication process and allowing interactions through mobile devices and an online portal.
"This was something that was definitely manual before," says Samantha Lodish, the health system's administrative director. "Now we're able to manage the healthcare of all our employees through the EHR. We definitely needed this and are thankful we have it."
TriHealth partnered with a third-party vendor that helps deliver value-based care services, and as a result, the health system achieved notable clinical and financial outcomes across a variety of payer contracts. TriHealth saw a change in revenue with a 70% rise in ambulatory settings and 30% in acute settings.
The health system also grew its primary care access by 25% across more than 230 primary care physicians and advanced practitioners. TriHealth says it now ranks near the top decile in cost and utilization as the top-performing ACO nationwide. with a larger payer—$7 million-plus in shared savings.
CMS is receiving pushback on its plan to create three new prolonged services codes.
Healthcare stakeholders, ranging from specialty societies to individual coding consultants, have urged CMS to abandon its plan to create three new prolonged services codes in commentssubmitted in response to the proposed 2023 Medicare physician fee schedule (MPFS).
Industry stakeholders described the three-code proposal for prolonged services as disappointing, burdensome, and confusing, according toPart B News.
For example, the American Association of Oral and Maxillofacial Surgeons said it was disappointed that CMS did not intend to accept the CPT® coding update to prolonged services and expressed concerns that two coding systems "will create administrative burden and undue confusion on the part of healthcare providers and coders."
The American Academy of Neurology predicted CMS’ proposed policy will "lead to confusion among practitioners and prove to be disruptive when medical specialty societies educate members about the correct coding for prolonged service."
Both specialty societies urged CMS and the workgroup to come to an agreement on how to define prolonged services for their revenue cycle.
According to Part B News, one commenter, a self-described professional billing consultant from Ohio, said the plan "makes no sense" and noted that it would not simplify coding. "If you are seeking 'administrative simplicity,' you should work it out with CPT and agree. The two of you having completely different numbers for the same [services] is going to be extremely confusing, " the commenter said.
CMS' original plan to use time to determine whether the treating physician or qualified health care professional (QHP) performed the substantive potion of a split/shared visit isn’t picking up any fans, based on a review of posted comments, Part B News said.
In the final 2022 MPFS rule, CMS said that it would allow practices to determine the substantive portion of the visit based on time or performance of key components for one year to allow providers to get used to the new policy. In the 2023 proposed rule, the agency announced plans to extend its policy another year.
However, the comments indicate that stakeholders want the option to bill based on time or key components—time or medical decision-making after 2022—to be permanent.
These aren't the first groups to urge changes of the rule.
Both the Medical Group Management Association and the American Hospital Association submitted comprehensive commentsto CMS in response to the rule as well.
The associations urged Congress to provide a positive update to the conversion factor, finalize the proposal to align telehealth services, and adjust subgroup reporting requirements under the MIPS value pathways, among other changes for 2023.
"Practices and coding educators will have to wait for CMS’ final decision. The final fee schedule is expected to be out in early November. However, the key lesson is that practices should be aware of what CMS is planning and wait until the final rule comes out to train staff," Part B News said.
OhioHealth has informed state regulators that it will lay off 58 revenue cycle staff in November.
OhioHealth, based in Columbus, Ohio, just filed a notice to state regulators announcing its plan to show 58 of its revenue cycle staff the door on November 4.
Those affected by the layoffs include accounts receivable specialists, coders, a manager of financial services and a supervisor of patient financial services, according to the notice. The layoff notice, signed by OhioHealth's vice president of human resources, says the layoffs are permanent and no bumping rights exist.
The health system filed the official notice about two months after The Columbus Dispatchfirst reported that OhioHealth was eliminating 637 information technology and revenue cycle management jobs, the system’s biggest layoff ever.
At the time, it was reported the move was part of a plan to outsource some services the system currently provides in house. Some of the other jobs eliminated were in information technology.
This news comes on the heels of the latest National Hospital Flash Report from Kaufman Hall, which said hospitals and health systems are experiencing some of the worst margins since the beginning of the COVID-19 pandemic, putting 2022 on track to become the worst financial year for the healthcare sector since the crisis first started.
OhioHealth is a network of 12 hospitals, ambulatory sites, hospice, home health, and other health services spanning 47 Ohio counties.
Shoring up technology has been a clear solution to alleviating staffing issues in the revenue cycle, and streamlining your current EHR system is a great place to start.
Electronic health record (EHR) systems are a critical to revenue cycles when looking to improve the patient experience and create better clinical outcomes, but revenue cycle leaders may need to rethink their optimization approach before it's too late as continued workforce shortages and supply chain disruptions may make it more difficult to enhance your EHR.
Almost 60% of health systems and hospitals have more than 100 open roles to fill a recent survey spotlighted, with one in four finance leaders needing to hire more than 20 employees to fully staff their revenue cycle departments.
Shoring up technology and automation has been a clear solution to not only alleviating staffing issues in the revenue cycle but making the administrative process more efficient overall, and streamlining your EHR system is a great place to start.
Julie McGuire, managing director at the BDO Center for Healthcare Excellence & Innovation, spoke with HealthLeaders on why EHR systems need to be optimized now and how revenue cycle leaders can get started.
HealthLeaders: Why is it important for revenue cycle leaders to have an optimized EHR system?
Julie McGuire: Revenue cycle leaders have the opportunity to lead their organization in a time of continued disruption, marked by decreased cash flow, labor shortages, and the implementation of digital solutions. Having an optimized EHR maximizes the value of investments. It can decrease integration complexities and ensure staff members are working at the top of their capabilities effectively and efficiently.
An optimized EHR can also help with optimizing revenue cycle functions, including improving work queues for faster actions on denials or referral responses and improving scheduling templates to open access. Another opportunity to reduce open encounters and lag charge time is to optimize clinical documentation tools and templates; this should also improve provider satisfaction and decrease provider moral injury. Taking the friction out of the referral process will lead to more satisfied referring providers and patients.
HL:With staffing shortages at an all-time high, how can revenue cycle leaders leverage EHR technology to help with this?
McGuire: Taking advantage of automated workflows and activities where possible should help to reduce the impact of labor shortages. Optimizing dashboards and analytics on key metrics like denials can help leaders determine where staff should focus. EHR technology can also be used to boost the efficient use of the patient portal, so patients can take the lead on scheduling appointments, online check-in and arrival, paying bills online, and obtaining their records.
HL:What are some tips revenue cycle leaders need to know in order to streamline and optimize their EHR?
McGuire: There are a few main areas I would highlight:
First, be well-versed in the functionality your organization has implemented already but may not have been adopted in your department.
Second, know the updates and features your EHR has available that will support organizational goals. Have conversations with your IT partners on the significance of implementing an effective EHR system to drive value for the organization.
And third, understand what your EHR can do to possibly reduce the need for a third-party system. It can reduce the overall application costs to the organization and decreases complexity for staff who may be working in multiple systems.
Remember, by optimizing its EHR, health systems are closing the value gap on the investment. Taking full advantage may improve operational efficiencies by decreasing integration complexity, reducing overall IT costs, and improving users' efficiency. And know that it doesn’t have to be expensive. Optimization doesn't have to mean overhauling your whole system.
HL: So then what incremental, low-cost changes can make a difference when looking to streamline?
McGuire: Break down your overall optimization plan instead of focusing on a large overhaul.
For example, first just focus on the patient experience and maximizing the patient portal. Another opportunity is to look at maximizing the reports/dashboards the EHR has to offer so concerns can be addressed right away. It's important to optimize the documentation and ordering tools for a high revenue generating specialty. Another option is to take a struggling specialty within your organization and optimize their documentation tools.
Medical groups are urging Congress to provide a positive update to the Medicare conversion factor as well as other changes for 2023.
The Medical Group Management Association (MGMA) and the American Hospital Association (AHA) both submitted comprehensive comments to CMS in response to the 2023 Medicare Physician Fee Schedule (MPFS) proposed rule.
The MGMA is urging Congress to provide a positive update to the conversion factor, finalize the proposal to align telehealth services, and adjust subgroup reporting requirements under the MIPS value pathways, among other changes for 2023.
The breakdown of the MGMA's key recommendations are as follows.
Urge Congress to provide a positive update to the Medicare conversion factor in 2023 and all future years.
MGMA is deeply concerned with the estimated reduction to the 2023 conversion factor and its potential impact on medical group practices, MGMA said in its statement.
"The cuts stemming from the 4.42% decrease in the CY 2023 conversion factor paired with the potential impact of Statutory Pay-As-You Go are simply unsustainable," the group said.
According to the MGMA, in poll conducted last month, 90% of medical practices report that the projected reduction to 2023 Medicare payment will reduce access to care.
Finalize the proposal to align telehealth services with the Consolidations Appropriations Act.
The MGMA is urging CMS to finalize the proposal to align telehealth services with the 2022 Consolidations Appropriations Act and continue to allow certain telehealth services to remain on the Medicare telehealth services list for 151 days after the expiration of the public health emergency, the MGMA said. The MGMA is also requesting CMS continue to cover and pay for audio-only visits permanently.
Adjust subgroup reporting requirements under the MIPS value pathways reporting option.
The MGMA says doing so will better reflect practices' team-based approaches to care and alleviate unnecessary additional administrative hurdles.
"MGMA has long advocated against requiring practices to form subgroups for quality reporting activities. Practices leverage every member of the clinical team to support effective and patient-centered care. Quality reporting should support the team-based approach to care and not undermine it," the group said.
The MGMA’s SVP of Government Affairs Anders Gilberg echoed these concerns in his statement.
"Staffing shortages jeopardize patient outcomes and increase costs for practices and waste for the healthcare system. Looking ahead to Medicare payment policies in CY 2023, each proposed policy must be considered in the context of the current state of the healthcare system; one in which practices do not have excess time, staff, or resources to devote to administratively burdensome tasks that neither add value nor improve the quality of care provided to patients," Gilberg said.
The AHA also released comments on the rule, many of which resounded the MGMA's.
According to the AHA, it has "strong concerns" about CMS' proposed changes to the Medicare economic index and urges the agency to pause its update of the index.
"In addition, we continue to have concerns about the feasibility of the MIPS value pathways, and believe much work remains to be done to ensure they result in fair, equitable performance comparisons across MIPS clinicians and groups," the AHA said.
The AHA said while it appreciates CMS' proposals to improve access to behavioral health services, the association questions the utility and adequacy of the proposals related to family psychotherapy and chronic pain management.
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 August, including payment rate updates and revised COVID-19 billing guidance.
Here are the five updates you need to know.
Prepare for your organizations' payment rates to possibly change on October 1.
In August, CMS published the fiscal year (FY) 2023 IPPS final rule. CMS projects an increase in operating payment rates by 4.3% based on a projected hospital market basket update of 4.1% reduced by a 0.3% productivity adjustment and increased by a 0.5% statutory adjustment.
This operating payment rate is significantly higher than the 3.2% rate from April's proposed rule and follows a trend with the other final payment system rules released thus far in 2022 where the payment rate in the final rule is higher than that from the proposed rule.
CMS finalized a return to using the most recent available data (including the FY 2021 MedPAR claims and the FY 2020 cost reports) for FY 2023 rate-setting with some modifications to account for any impact COVID-19 may have had. This includes calculating two sets of relative weights–one including COVID-19 claims and one excluding COVID-19 claims–and averaging those out to determine FY 2023 relative weight values. A full accounting of additional modifications CMS will make for rate-setting is discussed in the rule.
Other policies finalized in the rule include:
Approving 25 technologies for new technology add-on payments for FY 2023, but not continuing with a one-year extension for certain new technologies that are out of their newness period despite the authority to do so due to the public health emergency.
Due to certain statutory language and a recent federal court ruling (Milton S. Hershey Medical Center v. Becerra), CMS is modifying policies for teaching hospitals as well as for certain providers and cost years to address situations for applying the full-time employee (FTE) cap when a hospital's weighted FTE count is greater than its FTE cap.
As it has in other payment system rules for FY 2023, CMS is finalizing a 5% cap on any decrease to a hospital's wage index from its wage index the prior FY.
The rule also contains a variety of quality reporting program changes and several changes to policies regarding maternal health. CMS finalized a proposal to create a new "birthing-friendly" hospital designation effective fall 2023.
As mentioned previously, in April CMS proposed an IPPS increase of 3.2% for FY 2023, an additional $1.6 billion. However, that proposal drew flak from the hospital lobby. The Federation of American Hospitals (FAH) called the proposed increase "woefully inadequate."
"It does not reckon for the hyper-inflation, staffing crisis, and the continuing pandemic, which will impact resources necessary for patient care well into the future," FAH said in April.
However, the bumped reimbursement rate in this final rule "pleased" the American Hospital Association (AHA).
"This update still falls short of what hospitals and health systems need to continue to overcome the many challenges that threaten their ability to care for patients and provide essential services for their communities," AHA Executive Vice President Stacey Hughes said in a media release.
"This includes the extraordinary inflationary expenses in the cost of caring hospitals are being forced to absorb, particularly related to supporting their workforce while experiencing severe staff shortages," Hughes says. "We will continue to urge Congress to take action to support the hospital field, including by extending the low-volume adjustment and Medicare-dependent hospital programs."
The rule is effective October 1, 2022.
CMS is requesting information that may pertain to your revenue cycle.
Also this month, CMS published a request for information in the Federal Register regarding how Medicare can work to improve equity, high-quality, and person-centered care through Medicare Advantage (MA) in a way that is affordable and sustainable.
Some of the specific questions CMS asked for input on include effective approaches to handle social determinants of health, what types of supplemental benefits MA plans do or should provide, and how MA plans use prior authorization.
The use of data for MA plan and program improvement is also found throughout the request. Specific and detailed asks concern what can be done to better leverage data for better outcomes. Some examples include:
The best data to advance equity. CMS seeks better data related to race, ethnicity, and language; sexual and gender identity; people with disabilities and language/communication hurdles; cultural identity and religious preferences; socioeconomic need; and people in rural and underserved communities.
A focus on socioeconomic data. CMS adds specific questions, including MA plan challenges in "obtaining, leveraging, or sharing such data."
Supplemental benefit use and outcomes. To improve both, CMS asks what "standardized data elements" it could collect and how they would also aid DOH, equity, and cost-sharing burdens.
Applications for utilization management (UM). With a Senate bill aimed to improve PA headed to the house, CMS wants to know which of its data, if any, help with UM/PA application and how MA plan data could align for better efficiency.
Value-based contracting. Data to assess value-based contracting models within the MA program.
Competition dynamics. CMS seeks data on vertical integration and its MA market impact.
CMS released more guidance for your revenue cycle staff on COVID-19 billing.
On August 16, CMS updated its FAQsfor Medicare providers regarding COVID-19 billing. CMS published two new FAQs in the document regarding Medicare coverage and billing for COVID-19 testing done solely for travel purposes.
For example, CMS was asked if it is appropriate for a clinical laboratory to bill and accept cash payments from Medicare Part B beneficiaries for COVID-19 testing solely for the purposes of travel.
According to CMS' answer to this question, providers are required to submit claims for Medicare-covered services. However, in general, if a service is not covered by Medicare because it is not within the scope of a Medicare benefit, providers may bill and accept direct payments from beneficiaries for those services.
CMS said it strongly encourages providers to issue an advance beneficiary notice of noncoverage for care that is never covered because it does not meet the definition of a Medicare benefit, including COVID-19 testing performed solely for the purposes of travel.
Did CMS just lighten the load for your revenue cycle staff?
On August 17, CMS announced it is discontinuing the use of certificates of medical necessity and durable medical equipment information forms for claims with dates of service on or after January 1, 2023.
CMS said it reached this decision due to stakeholder feedback that these forms are duplicative and burdensome, and CMS said that submission of these forms is particularly burdensome for small or rural providers.
Another OIG audit highlights the importance of accurate coding.
On August 23, the OIG published areview of whether select diagnosis codes that Cigna HealthSpring submitted to CMS for use in the risk adjustment program complied with federal requirements.
The OIG conducted the audit by sampling 200 enrollees with at least one diagnosis code that mapped to a hierarchal condition category (HCC) for 2015. This resulted in 1,470 HCCs associated with these enrollees. The OIG found that 69 of the 1,470 HCCs were not supported in the medical record, a far lower error rate than the OIG typically finds in these audits.
The OIG also found that there were an additional 18 HCCs for which the medical records supported diagnosis codes that Cigna HealthSpring should have submitted to CMS but did not.
Therefore, the risk scores for these sampled enrollees should have been based on 1,426 HCCs instead of 1,470, and Cigna HealthSpring received $39,612 in net overpayments for these sampled enrollees.
The OIG recommended that Cigna HealthSpring refund the federal government for the $39,612 in net overpayments and improve its policies and procedures to prevent, detect, and correct noncompliance with federal requirements for diagnosis codes used in risk-adjusted payment calculations.
Cigna HealthSpring disagreed with the OIG's findings and recommendations from the draft report and questioned the OIG’s audit and statistical sampling methodologies. The OIG revised some of its original findings and recommendations but maintained that its methodologies were reasonable and properly executed.
The number of non-physician providers (NPP) submitting radiology service claims saw an increase from 2017 to 2019.
According to a study by the Harvey L. Neiman Health Policy Institute, the number of radiology practice employed NPPs submitting Medicare claims increased from 523 in 2017 to 608 in 2019, a 16.3% relative increase. NPP total work relative value units increased to a slightly greater extent (17.3%) and varied significantly across categories of services, the study said.
When the researchers assessed claims submitted by NPPs by clinical category, 98.7% of NPP services were involved clinical evaluation and management, invasive image-guided procedures, and imaging interpretation, the study said. Among these, invasive procedures accounted for the highest proportion of total NPP work relative value units.
Evaluation and management services accounted for the second highest number of NPP work relative value units and exhibited a 40% increase from 2017 to 2019: from 80 to 111 thousand, respectively. This made up a growing proportion of NPP work effort.
Regarding the potential impact of the observed growth in NPPs billing for radiology services, senior study author Richard Duszak Jr, MD, said, "Our aggregate claims-based analysis does not allow us to study comparative outcomes of services rendered by NPPs nor opine on whether the observed trends are either good or bad for the specialty or its patients. Such questions will require further study and analysis."
The study, published in the Journal of the American College of Radiology, was based on CMS' databases of doctors and clinicians who participated in Medicare.
As more claims roll in and staffing needs deepen, revenue cycle leaders should work on solutions to make up for potential lost revenue.
Patient volumes and subsequent claims will only continue to increase. In fact, medical claims are now on the rise after being suppressed during the early stages of the COVID-19 pandemic.
On top of this, there is mounting pressure on hospital margins. Between June and July of this year, hospitals' financial performance plunged, according to the latest National Hospital Flash Report from Kaufman Hall.
As healthcare organizations look to strengthen the bottom line coming out of the pandemic, it will be increasingly important for leaders to address revenue cycle management gaps—and do so while balancing the lack of staffing.
Belinda Cridge, revenue cycle management expert at HGS Healthcare, spoke with Healthleaders to discuss what revenue cycle leaders can do to alleviate these issues as pressure intensifies.
Increasing revenue and closing gaps
"With inflation at a 40-year high everyone has less buying power, which will likely result in a larger volume of self-pay, accounts-receivable balances." Cridge says.
This is why it's important for revenue cycle leaders to develop processes to collect payments pre-service and provide patients with better good-faith estimates.
"Another area of revenue loss is typically retro-eligibility and coordination of benefits. Developing exception reports, retro-eligibility reports, and paid-claim databases are some of the best ways to avoid black holes as it relates to this area of loss," Cridge said.
Pinpointing the area within your revenue cycle with the most gaps is also very important.
Within revenue cycle management, clinical denials for medical necessity and level of care downgrades are costly. Post-pay audits were temporarily put on hold during COVID-19, and now organizations are seeing a huge rise in these audits, Cridge says.
"Data science and analytics can help providers track root causes of unpaid claims and avoid these going forward," Cridge says. "Payer rules are cumbersome and some providers, by matter of routine process, provide certain levels of service irrespective of the payer."
While creating a plan of action for revenue cycle leaders is a great start, it can seem like an uphill battle as revenue cycle staffing shortages take hold.
According to a recent survey, more than 57% of health systems have more than 100 open roles to fill, with one in four finance leaders needing to hire more than 20-plus employees to fully staff their revenue cycle departments.
Since staffing and revenue cycle talent shortages will continue in the near-term and exacerbate the pressure on cost reduction, Cridge says she recommends three steps to immediately enhance the revenue cycle to help increase the bottom line and ease staffing deficiencies.
One: Invest in a consultative review of accounts receivable to identify the top three to five areas causing the most revenue bleed and develop plans and timelines to fix them.
For example, billing processes—from bill creation through payer acceptance—can greatly benefit from being fully automated, Cridge says.
"Automating these processes are typically inexpensive and can have an immediate impact on revenue," she said.
Two: Review your small balance write-off policies.
"It's easier to get small balance claims paid if there's a vendor partner who has robust services and the depth of experience to monitor and work through these efficiently," Cridge said.
Three: Develop post-pay audit processes by payer.
Significant dollars are lost due to upfront tasks not being done to avoid recoupments, Cridge said.
Cridge has put her own tips to work as she recently helped to leverage data analytics to identify trends in denials/underpayments for an organization.
The initial findings showed that, over a period of two years, one payer underpaid $120K in oncology payments, while another payer did not pay a single appeal, she said. Cridge also found that there were 14,000 unnecessary follow-up attempts on claims that were being processed to pay.
"Revenue cycle leaders should invest in a data center, a data scientist, and revenue cycle subject matter expert to help make up lost revenue. The initial set-up may be overwhelming, but the ongoing control will reduce the need for manual trending, alleviate staffing issues, and avoid revenue loss," she says.
