A large health system allegedly issued claims for urgent care services billed at a higher level of service than received by patients.
St. Elizabeth’s Hospital of the Hospital Sisters Health System, a multi-institutional healthcare system that sponsors 15 hospitals in 14 communities across Illinois and Wisconsin as well as an integrated physician network, is under fire.
The system agreed to pay $12.5 million to resolve allegations from a whistleblower lawsuit which alleges it committed billing errors that may have resulted in an overpayment for services, according to a release from the U.S. Attorney’s Office for the Central District of Illinois.
The whistleblower lawsuit alleges that the hospital submitted these claims for urgent care services billed at a higher level of service, according to the news release. When the errors were brought to the attention of St. Elizabeth, the hospital fully cooperated with the Department of Justice’s investigation.
St. Elizabeth is not admitting any wrongdoing but has agreed to settle the claims to avoid the expense and uncertainty of litigation. The claims resolved by the settlement are allegations only, and there has been no determination of liability, the release said.
Under the False Claims Act, private citizens can bring suit on behalf of the United States and share in any recovery.
In the Yale whistleblower case, the settlement agreement totaling $560,718 should resolve allegations of overbilling by Yale, violating federal and state laws for submitting false claims to Medicare and Medicaid for services billed by physicians when they should’ve been billed at the lower reimbursement rate of mid-level providers, according to the Department of Justice.
Revenue cycle leaders should ensure all their teams—everyone from coders to providers—understand the financial penalties associated with False Claim Act violations and be familiar with all other compliance penalties.
The AVP for corporate case management at Ardent Health Services details how its technology caught $1.76 million in potential missed inpatient revenue.
Automation in the revenue cycle is not an if, but when. As revenue cycle leaders know, automation has the power to transform the business of healthcare by streamlining repetitive tasks to improve efficiency and reduce financial waste while providing administrative support.
One healthcare system has done just that by implementing automation for strategic revenue management. Hillcrest HealthCare System, the Oklahoma market of Ardent Health Services, has created a system in which processes are designed to best serve patients instead of the other way around.
As a result, since technology implementation in 2020, Hillcrest’s clinical staff now focuses their effort on patients, not the administrative work, ultimately saving the hospital time and money.
HealthLeaders recently touched based with Rikki Moye, assistant vice president of corporate case management, at Ardent Health Services, about how the system was able to shift its focus back to its patients through technology.
The health system represents eight major hospitals in the area with over 1,200 licensed beds across the system. Moye was brought on as the vice president of case management in 2016 to build a new case management model that prioritizes patients and is supported by processes instead of led by them, she said.
HealthLeaders: Tell us more about your role at the health system. Was it a challenge creating such a complex case management model?
Rikki Moye: It was a challenge to be sure, but eventually, I thought, ‘Instead of having siloed utilization review, care coordination, and discharge planning functions that sat side-by-side within Hillcrest, what would happen if that model was tipped on its side?’ I then realized that utilization review needed to be a top-down view of the patient where nurse resource managers could oversee the efficient use of resources for each patient as they progressed through their stay, and social work and care coordination could work together to manage the patient safely and efficiently with a seamless discharge handoff.
This model we call the ‘Right Care Case Management Model,’ encompasses five ‘rights:’ The right patient, care, setting, documentation, and billing/payment. Using this approach, patients are placed at the center of the conversation, with communication and care facilitated by a resource manager following that person throughout their encounter and beyond.
HealthLeaders: After implementing this new model, why was it important for your organization to throw new technology into the mix?
Moye: Hillcrest is very large in scale, so in order to set up the Right Care Case Management Model where patients come first and processes are designed to serve them best, we needed the right technology.
Historically, it’s been challenging to introduce technology that would enable this process to the level we need. The labor required is too great, the quantity of data needed is too vast, and consistency and leadership at scale are hard to achieve. However, in mid-2020, we implemented XSOLIS’ CORTEX® platform to address those challenges and allow clinical staff to refocus their efforts on the patient, not administrative work. With it, the staff has access to a real-time, artificial intelligence-driven view of each patient’s medical necessity, prioritizing cases by revenue sensitivity and risk while also using the platform as a channel to communicate with payers.
The traditional Milliman and InterQual care approaches are binary, meaning it’s either red or green and then you have to move on. It’s also open to nurse interpretation, which means it’s at high risk for human error. Our new platform provides an agnostic, analytical assessment of patients, combined with a nurse’s clinical care skills, which enhances and encourages clinical expertise rather than defaulting to the binary clinical decision tree where you basically check your critical thinking skills at the door.
HealthLeaders: Where were you seeing gaps in the revenue cycle that made you realize a change needed to be made?
Moye: The problems we faced were the same ones that plague care management across the industry: unstructured data that is difficult to harness, gaps in compliance data, lack of consistency with education or supervision, and most impactfully, no way to prioritize the work that has the most significant downstream impact.
HealthLeaders: Case managers are arguably pretty in the weeds when compared to other leaders in the revenue cycle, so were there any hurdles with administrative or clinical staff buy-in? How did you make your case for adding in a new solution like this?
Moye: I was originally brought into bridge operations, strategy, and structure, and provide a gap analysis for where Hillcrest could go in the future. At the time, there was not a lot of case management structure at the market or the corporate level, and the organization was looking for a new way of doing things.
There’s always a learning curve when implementing new technology, but the platform is now a vital part of our nurses’ jobs. The way the tool is set up, it presents medical records and quantifies data in an extremely intuitive way, telling nurses upfront where their day needs to start so they don’t feel like they’re constantly trying to figure something out. In fact, a company-wide study found our nurses got back roughly two hours in their day once it was implemented.
The tool has also improved job satisfaction among utilization review nurses, as well as the relationship between Hillcrest’s hospitals and the payers it interacts with. Hillcrest has a contract with a national payer who also uses the platform, greatly improving our communication and contributing to a better working relationship because everyone sees the same thing. Nurses now know when to push back on decisions, and payers know when to spend time reviewing. Plus, other payers who aren’t currently on the platform are learning about the benefits, and the smoke and mirrors around the term ‘criteria’ are starting to disappear.
HealthLeaders: What kind of outcomes and improvements have you seen in your revenue cycle since implementing this tool?
Moye: In the first two years, CORTEX’s inpatient-only alerts have caught $1.76 million in potential missed inpatient revenue. Along with a 12% reduction in observation rates, this has resulted in an additional $3.28 million in inpatient revenue.
We were also able to improve observation-to-inpatient conversion rates from 27% to 52% while reducing inpatient-to-observation downgrade rates to about 4%, a 50% sustained reduction. Inpatient denials were reduced by 102.34% in the first year.
HealthLeaders: What will you be focusing on for the rest of this year and into 2024? What other goals do you have for revenue cycle improvement?
Moye: Our goals now include moving from a market/regional focus to an enterprise focus across all Ardent Health acute hospitals. Our ability to leverage technology to facilitate throughput and length-of-stay reductions is one of the successes of the Hillcrest team that we are sharing with other hospitals.
Yale New Haven Health and Northeast Medical Group have agreed to a hefty settlement for allegedly submitting false claims to Medicare and Medicaid.
The federal and state governments allege that the Yale New Haven Health and Northeast Medical Group submitted false Medicare and Medicaid claims, which has since resulted in a hefty settlement from the system.
The settlement agreement totaling $560,718 should resolve allegations of overbilling by Yale, violating federal and state laws for submitting false claims to Medicare and Medicaid for services billed by physicians when they should’ve been billed at the lower reimbursement rate of mid-level providers, according to the Department of Justice (DOJ).
The DOJ says the healthcare providers submitted the false claims between July 2014 and June 2020, and as a result, the providers improperly received between 10% and 15% more in Medicare and Medicaid reimbursements for the allegedly falsely billed services.
The allegations were initially brought in a lawsuit filed by a whistleblower, a former employee of Northeast Medical doctors’ group. According to the DOJ, the whistleblower will receive about $106,500 as her share of the settlement.
Yale New Haven Health and Northeast Medical deny the allegations but agreed to the settlement to avoid a protracted legal process, according to the settlement.
A situation like this is worst-case scenario for revenue cycle leaders, and leaders should ensure their organization’s billing practices are appropriate. Address any errors identified as soon as possible and remember to return overpayments and provide education to your staff as soon as errors are discovered.
One way to easily keep an eye on fraudulent billing practices is through an internal audit. If an internal audit determines that Medicare was billed inappropriately, your orginization is in potential violation of the False Claims Act.
Revenue cycle leaders should ensure all their teams—everyone from coders to providers—understand the financial penalties associated with False Claim Act violations and be familiar with all other compliance penalties.
The most recent status update shows the huge influx of disputes.
A total of 334,828 billing disputes have been filed through the independent dispute resolution (IDR) process, nearly 14 times more than initially expected, according to a recent status report.
Between April 15, 2022, and March 31, 2023, certified IDR entities rendered payment determinations in 42,158 disputes. Overall, certified IDR entities have closed 106,615 disputes as of the end of March, over four times the volume initially estimated for a calendar year, according to the report.
In addition to confirming an ongoing backlog of IDR cases, the update also revealed a high success for initiating parties (71%), which have largely been providers.
These results aren’t much of a change from previous findings of the IDR process backlog.
For example, a previous report from the third quarter of 2022 saw nearly four times as many disputes as the second quarter, totaling 71,915.
Of the total disputes initiated in that report, 23,107 were closed, 3,576 reached a payment determination, and 15,895 were found ineligible for the IDR process. The remaining closed disputes were either withdrawn by the disputing parties, were closed because the parties reached an outside settlement, or were closed for other reasons, such as incorrect batching, data entry errors, or unpaid fees.
The backlog of disputes from all reports is due to the review and processing time needed to determine the eligibility of disputes.
Providers and payers have struggled to get on the same page on how the IDR process should be settled, with medical associations filing multiple lawsuits contending the emphasis on the qualifying payment amount, or the median in-network rate.
CMS has an FAQ available for leaders needing to catch up on revenue cycle changes now that the public health emergency (PHE) has ended.
The COVID-19 PHE has officially concluded, and to assist providers during this transition, CMS released an FAQ to clarify the end to various waivers and flexibilities affecting the revenue cycle and beyond.
CMS will continue to pay providers approximately $40 per dose for administering vaccines through the end of the calendar year (CY) in which the vaccine’s emergency use authorization (EUA) declaration ends. The EUA declaration is distinct from, and not dependent on, the PHE, and it is still in effect. Starting January 1 of the year after the one in which the EUA declaration ends, CMS will align the administration payment rate for COVID-19 vaccines with the administration payment rate for other Part B preventive vaccines, which is currently $30 per dose.
These rates do not apply for Federally Qualified Health Centers, rural health clinics, or other settings that are paid at a reasonable cost for preventive vaccines and their administration. Medicare will also continue to pay approximately $36 plus regular administration fees for COVID-19 vaccines administered at home through the end of CY 2023.
The enforcement discretion that allows mass immunizers to bill Part B directly for vaccines furnished to skilled nursing facility (SNF) patients will end on June 20, 2023. “Beginning on July 1, 2023, SNFs will be responsible for billing vaccines furnished to SNF patients in a Part A stay,” stated the FAQ.
Medicare coverage of COVID-19 treatments are remaining the same. For diagnostic testing, beneficiaries can continue to receive COVID-19 PCR and antigen tests with no cost-sharing if the test is performed by a laboratory and ordered by a physician.
The three-day stay requirement for SNFs is no longer in effect. Any covered SNF stay that began on or prior to May 11, 2023, without a qualifying health stay (QHS) can continue for as many benefit days as the patient has available, given all criteria are met. However, covered SNF stays that begin after May 11 will require a QHS.
Many Medicare telehealth flexibilities have been extended through December 31, 2024. However, CMS noted that individuals will now no longer be able to receive routine home care via telehealth under the hospice benefit.
The FAQ detailed billing practices for the following codes now that the PHE concluded:
Q3014 (originating site facility fee) should not be billed unless the beneficiary is located within a hospital and receives a telehealth service from an eligible distant site practitioner.
G0463 (clinic visit) can be billed if a beneficiary is within a hospital and received an outpatient clinic visit, including mental/behavioral health, from a practitioner in the same physical location.
C7900–C7902 (remote mental health services) can be billed if the patient is in their home and received a mental/behavioral health service from hospital staff through the use of telecommunications technology and no separate professional service can be billed.
Additionally, hospitals are no longer able to bill Q3014 “to account for resources associated with administrative support for a professional Medicare telehealth service,” according to the FAQ.
Denials aren't going anywhere, but streamlining how you manage them will help improve revenue cycle operations.
Revenue cycle leaders are still feeling the stress as regulatory burdens and never-ending denials are putting massive strains on revenue cycles.
Even if your front, middle, and back-end revenue cycle is a well-oiled machine, payers aren’t shy about throwing a wrench in things. In fact, it’s not uncommon for payers to have complicated, multi-tiered structures and rules that seem to always be changing, regardless of their contracts.
One leader has found that using a targeted approach for denials by creating teams that work by payer, establishing regular meetings, and data tracking can help tremendously in denials management.
Frank Cantrell, corporate director of revenue integrity at Penn Highlands Healthcare, says that each facility’s issues with denials can vary, but there are several constants that can be applied to improve denials management.
Here are three tips Cantrell says revenue cycle leaders can use to streamline denials management:
Know your contracts. Knowing not just the agreed upon payment rates but knowing the language and what rights you have makes a big difference. Many hospitals do not share contract language with those working the denials. This puts those staff members at a disadvantage when dealing with the payers.
Payer calls. Establish regular (we do monthly) calls with your payer representative. We provide a spreadsheet of claim issues—both payment and denial issues—prior to the call. This gives the payer time to review them and come to the meeting with answers. We put the burden back on the payer to tell us why the denial is valid and how to resolve it moving forward.
Track your data. We track all our denials by payer, reason, etc. so we can use this during contract negotiations. We provide this information to our managed care contracting director. If you have data the payer cannot refute, you have a greater chance of getting concessions on the new contract.
Cigna recently made a big change in how they will pay certain claims.
Organizations will need to stand firm on compliance and reimbursement when its revenue cycle team submits evaluation and management (E/M) claims with modifier -25 as Cigna recently dropped a new policy.
According to Cigna, it created a new policy requiring submission of office notes with all claims including E/M codes 99212, 99213, 99214, and 99215 and modifier -25 when a minor procedure is billed.
Cigna said it will deny payment for these E/M services reported with modifier -25 if records documenting a significant and separately identifiable service are not submitted with the claim, and medical groups were quick to show their frustration.
For background, the revenue cycle coding staff report modifier -25 for E/M services on the same day of another service or procedure when it is performed by the same physician or provider.
So how can revenue cycle leaders create a plan for their staff to defend these claims?
The good news is revenue cycle staff from all sections of the organization can play a part in defending the revenue for modifier -25 claims, according to a recent Part B News webinar. For example, providers must create documentation that supports the modifier, coders need to monitor private payers for new policies, and members of the A/R team will need to keep an eye on these denials.
It’s important that the revenue cycle keeps an eye on these denials, teams make sure the documentation supports modifier -25, and they are quick to appeal any of those claim denials.
Creating a template unique to this Cigna requirement will also help. Staff can then modify and use the template when documentation is provided for prepayment approval, when they respond to a request for documentation to support a claim, or when they appeal a denial of an E/M visit reported with the modifier.
If you submit claims to Cigna, you should also have a process to ensure the required documentation goes out with claims that include modifier -25. If you forget, you can expect more time and more work to get reimbursed, according to Part B News.
Another way to lessen the blow is to create a targeted approach to Cigna denials. “My denials team works by payer,” Frank Cantrell, corporate director of revenue integrity at Penn Highlands Healthcare recently said. “They know their contracts backwards, forwards, and sideways.”
Cantrell believes it’s important for his team members to be critical thinkers with a high level of understanding, which is a necessity since each payer contract has varying nuances.
One leader has found that using a targeted approach by creating contract experts is a key to warding off payer denials.
Regulatory burdens and never-ending denials are putting massive strains on revenue cycles, and revenue cycle leaders tend to look toward one culprit: the payer.
Why payers?
Even if your front, middle, and back-end revenue cycle is a well-oiled machine, payers aren’t shy about throwing a wrench in things. In fact, it’s not uncommon for payers to have complicated, multi-tiered structures and rules that seem to always be changing, regardless of their contracts.
Unlike Medicare, which has standard, heavily documented rationales and processes for denials, appeals, and audits, almost anything goes when it comes to commercial payers. Each payer organization will have different rules and processes, and payers’ manuals and bulletins aren’t always easy to locate.
New policy changes can be imposed throughout the year and in the mid-contract period, adding substantially to the administrative burden. Staying compliant with payers is never-ending, and with an already strained revenue cycle staff it can be hard to find extra hands, and money, to keep up.
What can revenue cycle leaders do?
One leader has found that using a targeted approach for denials by creating teams that work by payer has helped tremendously.
“My denials team works by payer,” Frank Cantrell, corporate director of revenue integrity at Penn Highlands Healthcare told the NAHRI Journal. “They know their contracts backwards, forwards, and sideways.”
Cantrell believes it’s important for his team members to be critical thinkers with a high level of understanding, which is a necessity since each payer contract has varying nuances.
In addition to being experts in their contracts, having working knowledge of the middle revenue cycle is also important. “One thing I’ve found to be key is that all of my individuals either have a clinical or coding background,” Cantrell says. He says having that extra clinical coding edge makes a huge difference in denials management.
Also, having staff with diverse backgrounds is especially helpful when writing appeal letters, according to Cantrell. It also helps their team know where to go when looking for answers. He appreciates that his team is able to determine when it’s appropriate for other departments to weigh in on a denial.
“At that point, we become more the facilitator than the actual one working the denial,” he says. “If it’s not specific to our wheelhouse, we’ll get it to the right department. I'd have to have a huge team to handle every nuance of a denial.”
If your organization is struggling with denials after creating a more targeted approach like this, revenue cycle leaders should explore opportunities to involve other departments. For example, IT can also support documentation efforts by incorporating feedback on how to improve template functions, EHR interfaces, the placement and function of drop-down menus, and other user experience and interface issues, according to Cantrell.
Having revenue cycle staff allocated by payer will surely help to stay abreast of the seemly ever-changing payer rules. In fact, Cigna has recently come under fire for its new policy requiring submission of office notes with all claims including evaluation and management (E/M) codes 99212, 99213, 99214, and 99215 and modifier -25 when a minor procedure is billed.
Cigna says it will deny payment for these E/M services reported with modifier -25 if records documenting a significant and separately identifiable service are not submitted with the claim.
Making sure your revenue cycle team is on top of their game is a must when it comes to payer denials.
Revenue cycle success is closely tied to the patient experience, so make sure to keep the patient in mind and up-to-date as the PHE ends this week.
This week’s end in the COVID-19 public health emergency (PHE) will affect specific patient services, such as COVID-19 treatment and telehealth services. As the revenue cycle is closely tied to the patient experience, making sure staff is well-versed in these upcoming changes will not only create a more positive patient experience, but help streamline reimbursement operations during the transition.
Front-end staff especially may be fielding ample questions as patients notice changes in coverage and reimbursement this week. So, below is a summary of frequently asked questions courtesy of Revenue Cycle Advisor that clarifies what will and will not change for certain provisions once the PHE ends.
CMS said the federal government, individual states, or insurance companies may announce additional changes in the future, but for now, here are some changes staff should be aware of.
Q: Can our patients still obtain free COVID-19 vaccines?
A: For patients with Medicare, Medicaid, or coverage under the Children’s Health Insurance Program (CHIP), vaccines will be 100% covered until “the last day of the first calendar quarter that begins one year after the last day of the COVID-19 PHE,” according to CMS. As of now, this is expected to be September 30, 2024. While Medicare didn’t list an end date for vaccine coverage, Medicaid and CHIP coverage may change after that expected date. This is when the American Rescue Plan Act of 2021 (ARPA) provision, which requires these services to be provided without cost sharing, expires. It’s unclear whether coverage will change after that point.
Many people with private health insurance will still be able to get vaccinated without paying any additional money out of pocket. However, some private plans may ask patients to pay part of the cost if they get a vaccine from an out-of-network provider.
Q: Will COVID-19 tests still be covered for our patients?
A: For people with traditional Medicare, both COVID-19 PCR and antigen tests will still be free, provided they are performed in a lab and ordered by a physician or another qualifying healthcare provider. Medicare Advantage beneficiaries can still obtain tests, but they may have to pay a percentage of the costs.
“By law, Medicare does not generally cover over-the-counter services and tests,” said CMS. “Current access to free over-the-counter COVID-19 tests will end with the end of the PHE. However, some Medicare Advantage plans may continue to provide coverage as a supplemental benefit.”
Medicaid and CHIP beneficiaries will have the same coverage for COVID-19 tests until the last day of the first quarter that begins one year after the last day of the PHE—which means coverage will continue through September 30, 2024, if the PHE ends as scheduled. After that point, changes may be made.
Private insurers may or may not charge for COVID-19 laboratory tests. Some people will still be able to get free testing depending on their coverage, but others will need to pay out of pocket.
Q: How will the end of the PHE affect our patient’s COVID-19 treatment?
A: Treatment for COVID-19 will stay the same for Medicare beneficiaries once the PHE ends.
Medicaid and CHIP beneficiaries will still be eligible for treatment under the same rules that applied during the PHE until the last day of the first quarter that begins one year after the last day of the PHE (September 30, 2024). After that, coverage may continue but could vary by state.
People with private insurance will probably not see any changes related to treatment coverage.
Q: What will happen to telehealth coverage after the PHE ends?
A: Many telehealth services will still be available to Medicare beneficiaries through December 31, 2024, according to CMS. For example, telehealth services will continue to be available for those in any location, not just rural areas. Medicare will pay for in-home telehealth visits, and telephone telehealth visits are allowed if audio and video are too challenging for the patient. CMS provided additional details about the transition here.
Coverage may vary by state for those with Medicaid, CHIP, Medicare Advantage, and private health insurance.
The COVID-19 public health emergency (PHE) is ending this week, make sure your revenue cycle staff are prepared.
More than three years after the COVID-19 PHE was declared, it is now set to end on Thursday, which will be impacting revenue cycle reimbursement.
Multiple emergency declarations and waivers that were implemented granting flexibilities to state Medicaid operations and most healthcare organizations are coming to a halt, leaving revenue cycle staff scrambling to ensure minimal disruption to their billing and operations.
Here is a look at what could be affecting your revenue cycle:
Telehealth reimbursement waivers: These waivers allowed hospitals to provide telehealth services to patients without prior authorization, and reimbursements for telehealth visits were increased. With the end of the PHE, these waivers may end, and hospitals may have to seek prior authorization for telehealth services, and reimbursements may return to pre-pandemic levels.
Waivers for Medicare coinsurance and deductible payments: During the public health emergency, Medicare waived Part B coinsurance and deductible payments for COVID-19 treatment. With the end of the PHE these waivers may end, and hospitals may have to bill patients for the coinsurance and deductible payments, which could negatively impact your organizations' patient financial experience.
Suspension of Medicare sequestration: The PHE suspended the 2 percent Medicare sequestration, which was a reduction in Medicare payments to hospitals. With the end of the public health emergency, this sequestration may resume, reducing Medicare payments to hospitals.
Reintroduction of the three-day stay skilled nursing facility (SNF) requirement: To qualify for SNF reimbursement, Medicare patients must have first spent three consecutive midnights in the hospital as an inpatient. These inpatient days must meet medical necessity requirements, and the clock starts ticking when the physician writes the inpatient order.
In order to receive proper reimbursement, revenue cycle staff should be clear on the following Medicare requirements for SNF coverage:
The patient must have completed a three-day inpatient stay
The stay must have extended through three midnights, beginning at the time the physician wrote the inpatient order
Note that time spent in observation or the emergency department does not count toward the three-midnight requirement.
For even more information, HHS released a policy roadmap detailing policies that will simultaneously end with the PHE, as well as flexibilities that have been extended for various time periods.
As the end of the PHE inches closer, revenue cycle professionals must ensure their organization is in compliance throughout the transition. Review the transition roadmap and other fact sheets to determine the timeline of flexibility expirations.
