The 2023 OPPS and Medicare physician fee schedule final rules were top of mind in the revenue cycle this month.
Look at the top trending revenue cycle stories from HealthLeaders this month, both of which cover recent payment rate updates to hospitals and physicians.
CMS released the 2023 OPPS final rule that includes increased Medicare reimbursement and the establishment of a new provider type, but hospital groups say it's not enough.
CMS recently released the 2023 OPPS final rule, which brought increased hospital outpatient payment rates, the establishment of a new provider type, and 340B payment finalization.
According to the final rule, CMS has increased Medicare reimbursement for hospital outpatient departments by 3.8%, reflecting a hospital market basket increase of 4.1 percent and a 0.3 percentage point decrease for productivity. This is higher than the 2.7% update included in the proposed rule earlier this year.
Blow-back from the proposed payment rate increase of 2.7% may have played a role in the finalized amount of 3.8%.
Ninety percent of medical practices reported that the payment cuts found in the 2023 Medicare physician fee schedule would reduce access to care, the MGMA says.
Physician payment cuts are coming, significant changes to E/M services are finalized, and key reporting revisions are hitting telehealth and audio-only services, according to the final 2023 Medicare physician fee schedule.
Proposed payment cuts that drew vocal criticism from physician advocacy groups will move forward as planned, as CMS announced a 4.5% reduction to the 2023 Medicare Part B conversion factor (CF), effective January 1.
The CF will fall to $33.0607 in 2023, down from $34.6062 in 2022, largely due to budget neutrality adjustments. The final CF for 2023 is two cents lower than the rate CMS first proposed in July, according to Part B News.
The anesthesia conversion factor will also take a hit next year, down 4.4% as proposed.
CMS finalized new procedures that will be subject to prior authorization in 2023.
Earlier this year in the 2023 OPPS proposed rule, CMS brought forward a proposal to require prior authorization for an additional service category: facet joint injection procedures.
At the time, CMS said this would ensure Medicare beneficiaries receive medically necessary care while protecting the Medicare Trust Funds from unnecessary increases in volume by virtue of improper payments. This would happen without adding new documentation requirements for providers, CMS said.
Now, CMS finalized adding facet joint interventions to its hospital outpatient department prior authorization list in the recently released 2023 OPPS final rule, but with one change: In response to feedback, CMS scrapped its proposed March 1, 2023, effective date for this proposal. Instead, facet joint injection procedures will be subject to prior authorization starting July 1, 2023.
“Prior authorizations for joint injections will potentially affect providers not affected by the prior cosmetic or major back procedure requirements,” says Kimberly A. Hoy, JC, CPC, director of Medicare and compliance at HCPro. “CMS’ delay until July 1, 2023, in line with prior delays, rather than going forward March 1, 2023, will give providers needed time to prepare.”
CMS continues to cite the need to control unnecessary increases in volume as the deciding factor behind added prior authorizations each year.
CMS has seen a marked increase in the volume of facet joint injection procedures, so it’s not unreasonable for it to take steps to ensure they’re medically necessary, Ronald Hirsch, MD, FACP, CHCQM, CHRI, vice president of regulations and education at R1 RCM, told NAHRI.
Although prior authorization can be burdensome to the front-end revenue cycle, it can help avoid at least some denials on the back-end.
“From the provider side, it seems better to have assurance of payment prior to performing the procedure instead of incurring the costs of performing the procedure and then being denied payment afterwards,” Hirsch says.
While CMS agrees with that statement and says it will ensure that this measure will not burden patients or providers, many providers are not so sure. For example, as the American Medical Association previously found, prior authorizations of medical treatments and services has a negative impact on both patients and providers.
The American Medical Associations survey found that 93% of physicians reported that prior authorization led to delays of necessary care (14% always, 42% often, and 38% sometimes), and that 82% of physicians reported that the prior authorization process leads patients to abandon treatment (3% always, 24% often, 55% sometimes).
More than 1,000 practicing physicians participated in the American Medical Association survey, with 40% working as primary care physicians and 60% working as specialists.
As CMS is bound to add more procedures to the prior authorization list moving forward, time will tell of the effect on the front-end revenue cycle.
CMS recently released sample formats for hospital price transparency files to help revenue cycle leaders comply with the requirement.
As price transparency requirements push forward and with a wide lack of adoption from hospitals, CMS is trying to help revenue cycle leaders streamline their processes by offering sample formats.
CMS is offering three voluntary sample formats (wide, tall, and plain) that hospitals may use to meet the federal requirement to make certain standard charges publicly available through a machine-readable file.
At the same time, CMS also posted a sample data dictionary for the wide and tall formats.
While some organizations already have systems in place to adhere to price transparency requirements, opportunities still exist to adjust outdated revenue cycle processes, including creating the necessary machine-readable file.
"Revenue cycle leaders need to first make sure they are following CMS' guidelines to complete a comprehensive, machine-readable file of all services and items," Connie Lockhart, director of strategy and operations at Impact Advisors, said.
"Ensure all requirements are met—like how a separate file must be posted for each hospital. And be cognizant of multiple hospitals operating under a single hospital license with different sets of standard charges."
Also, ensure that list is posted on a publicly available website.
Once completed, make sure to post a display in a publicly available website of 300 shoppable services in a consumer-friendly format. This should include the 70 CMS-specified, shoppable services, Lockhart says. Revenue cycle leaders should also establish a cadence to ensure both displays are updated annually, Lockhart says.
Once the basics of price transparency are in place, like creating a machine-readable file, revenue cycle leaders can then move to streamlining other areas of the requirement.
A Pennsylvania doctor, Muhamad Aly Rifai, was indicted with four counts of healthcare fraud for fraudulently billing Medicare for services not provided, or not provided at the level which was claimed, the Department of Justice (DOJ) recently announced.
According to the indictment, the defendant was a licensed psychiatrist, that for several years, routinely and improperly billed Medicare for services which he did not provide to Medicare beneficiaries and nursing home patients.
The DOJ said his fraud included the following:
Billing for treating dead beneficiaries
Billing for treating the same patient at the same time at different nursing homes
Billing for providing more than 24 hours’ worth of services to patients on a single day
The indictment further alleges that the defendant routinely billed for higher levels of care than he or his staff provided to nursing home patients. According to the Indictment, despite not having actually seen the patient, Rifai added a pre-printed stamp to medical progress notes to support billing for psychological and add-on services which were not provided by his staff.
From about January 2015 until October 2022, Rifai obtained Medicare payments of at least approximately $1.36 million based on fraudulent claims, the DOJ said. If convicted, the defendant faces a maximum possible sentence of 40 years in prison and a fine of up to $1 million.
The MGMA recently detailed five ways the government can help alleviate burdens from certain requirements under the No Surprises Act.
The Medical Group Management Association (MGMA) recently provided written comments to the HHS, the Department of the Treasury, and the Department of Labor regarding rulemaking for the advanced explanation of benefits (AEOB) and good faith estimate (GFE) requirements of the No Surprises Act.
The No Surprises Act, which became effective January 1, contains provisions that protect patients from surprise medical billing and out-of-network emergency care costs not reimbursed by insurance. And as we have seenfrom other letters penned to the departments, many medical associations are finding the AEOB and GFE requirements to be the most burdensome right now.
According to the MGMA, to address ongoing concerns regarding the GFE and AEOB requirements, the departments should:
Not enforce AEOB requirements until there are workable solutions that are developed, tested, and implemented.
The departments stated they would delay implementation of the AEOB policies until rulemaking has occurred, but the MGMA says this is not enough time for the industry to roll out and deploy the necessary standards needed to implement these requirements.
Allow for patients to opt-in to receiving AEOBs and GFEs.
At a minimum, the MGMA says the departments should allow for practices to apply for a hardship exemption, which would give them additional time to apply.
Not yet rely on new, fast healthcare interoperability resources-based standards to implement AEOB requirements.
Whichever standard the departments support should take into consideration medical practices of all sizes and regions, as well as those who are under-resourced, the MGMA said. In addition, the MGMA says a standard must be developed, tested, and readily available to medical groups before the AEOB requirements are implemented and enforced.
Extend the enforcement discretion for the convening provider/facility and co-provider/facility provisions for GFEs.
The MGMA says enforcement discretion should continue until appropriate standards have been developed, tested, and implemented by group practices.
Continue soliciting input and working with stakeholders, such as medical groups, to implement workable policies that empower patients, but not at the expense of delivering care.
A new study says drug companies reduce access to care by limiting 340B community pharmacies.
As 340B payments remain in the spotlight, a new study says drug companies are limiting 340B pricing with community and specialty pharmacies which in turn is having an adverse impact on access to care for patients and communities across the country.
In July, the Supreme Court unanimously ruled that cuts to hospital reimbursement under the 340B drug discount program were unlawful. At the time, the justices said that HHS' failure to survey hospital costs before enacting the cuts exceed the agency's authority under the Medicare statute, making the decision to reduce 340B reimbursement unlawful.
The ruling was the culmination of a court battle stretching back to 2017, when CMS finalized cuts to hospital reimbursement under the 340B program in the 2018 outpatient prospective payment system final rule.
According to the study, the average 340B critical access hospital (CAH) reported annualized losses of approximately $507,000, and the average disproportionate share hospital reported annualized losses of nearly $3 million.
On average, CAHs reported 44% of their total 340B savings coming from community and specialty pharmacies, with several CAHs reporting that their entire 340B savings come from these arrangements, the AHA study said.
“Overall, 10% of responding hospitals reported average annualized losses of $10 million or more, illustrating the magnitude of the harm that drug companies’ actions have on 340B hospitals and their ability to care for their patients,” the study said.
“This important new report shows how unlawful actions by drug companies to restrict 340B discounts to community and specialty pharmacies are directly reducing access to care and services for patients and communities, especially those in rural areas,” AHA Executive Vice President Stacey Hughes said in a statement.
“Drug companies are limiting discounts that help hospitals provide free care for uninsured patients, services in mental health clinics and many community health programs. To protect access to care, we continue to urge the Department of Health and Human Services to aggressively use all tools available to stop these harmful tactics from drug companies,” Hughes said.
The report is based on a survey of more than 300 hospitals and health systems participating in the 340B program conducted earlier this year by the AHA.
Patients are now required access to medical records and information regarding enrollment, payment, and claims adjudication, adding stress to revenue cycle staff.
In October, the definition of electronic health information within the 21st Century Cures Act was expandedto include all electronic protected health information for patients. This means patients are now required access to their medical and payment records and any information used to make decisions about their care.
For example, this includes most data found in a patients' health record including medical records and billing records, enrollment, payment, claims adjudication, case or medical management record systems, and more.
In September, the AHA advocated for a one-year extension to this update citing a lack of resources to streamline these requests. According to the AHA's letter, "Despite our best efforts to educate our members, significant knowledge gaps and confusion still exist within the provider and vendors communities with respect to implementation and enforcement of information blocking regulations."
HHS obviously did not grant this one-year extension, and as access has been granted to patients for more than a month now, revenue cycle leaders are now seeing an influx of patient confusion and even demands for changes to their record—which goes beyond just the initial regulatory implementation worries cited by the AHA.
While access to information is of the utmost importance, should there be a line drawn for how much a patient sees behind the scenes?
When reviewing the updates under the Cures Act, Brian Murphy, branding director at Norwood, said a patients' access to "medical and billing records of course jump out at me. But so do the rest. Patients will have a much wider window into coverage determinations, cost of visits and procedures, nursing notes, op notes, and on and on."
Earlier this year, Chris Johnson, vice president of revenue cycle at Atrium Health, spoke with HealthLeaders about the patient billing experience and how access to too much information has been causing confusion for their patients.
"Quite frankly, when some patients see an insurer's use of CPT and ICD-10-CM codes, it can be like a foreign language, and it can cause real confusion," Johnson said.
Now patients have access to this information before the bill is even sent—and then some.
"Most coding/CDI/revenue cycle leaders expect scrutiny from payers, or peers, but typically don't think of patients. The patient has now entered the equation. I've already heard stories of patients objecting to coded diagnoses like major depressive disorder, drug abuse, and other sensitive conditions," Murphy said.
With these changes now in full swing, updating and streamlining processes may be needed.
"I think hospitals need to develop policies for how they plan to deal with patient objections, especially those that could result in quality or revenue impacts," Murphy advised.
Patients in the most affordable state still must work 269 hours to pay off an average hospital stay bill.
As hospital leaders work to offer affordable, transparent pricing through the No Surprises Act and rush to streamline billing practices to improve the patient financial experience, a new study sheds light on exactly how burdensome these hospital prices are for patients and how long they need to work to pay their bill.
The average cost of a hospital stay in the United States is $2,873 a day, with the average stay lasting 4.6 days, according to a recent report by ValuePenguin using data from the Kaiser Family Foundation and the U.S. Agency for Healthcare Research and Quality.
Using the average hourly earnings of residents of each state from the U.S. Bureau of Labor Statistics, researchers were able to calculate the number of hours of work required to pay off the bill for an average hospital stay.
Oregon was the least affordable state, requiring residents to work 646 hours to pay for the average hospital stay. It was followed by Utah (600 hours), New Mexico (581 hours), Ohio (581 hours), and California (572 hours).
Overall Wyoming was the most affordable state, requiring residents to work 269 hours to pay off an average hospital stay bill. It was followed by Mississippi (294 hours), North Dakota (324 hours), Iowa (334 hours), and South Dakota (336 hours).
Naturally, minimum wage workers would have to work considerably more hours to pay off an average hospital stay bill. On the higher end, a minimum wage worker in Utah would need to work 2,126 hours to pay off the bill. South Dakota is the most affordable state for minimum wage workers, requiring them to work 759 hours to pay off the bill.
The spotlight is on your revenue cycle's coding team as COVID-19 reporting sheds light on a multitude of post-acute conditions brought on by the virus.
A recent study published in the Journal of the American Medical Association Network Open found that between October 1, 2021, and January 31, 2022, providers used ICD-10-CM code U09.9 (post-COVID-19 condition, unspecified) to identify a multitude of post-acute conditions brought on by COVID-19.
The study was commissioned to examine how the diagnosis code was used in clinical practice over the four-month period in anticipation of helping public health professionals monitor post-COVID-19 symptoms and gain a better understanding of health risks associated with COVID-19 as the pandemic evolves.
Post-acute sequelae of COVID-19 are commonly documented in patients recovering from the infection weeks to months after acute infection. Code U09.9 is used to identify sequelae such as fatigue, muscle weakness, headache, and impaired lung function.
To examine how code U09.9 was used in clinical practice over the four-month period, researchers at Pfizer Inc. and Genesis Research reviewed 56,143 medical records for patients with a post–COVID-19 condition. Inpatient and outpatient claims data was aggregated from a HealthVerity database.
Researchers found that ICD-10-CM code U09.9 was used immediately after it was released on October 1, 2021, and that its use plateaued in January 2022. Providers used this code to represent various symptoms spanning multiple body systems, including but not limited to:
Anomaly of breathing
Disturbance of smell and taste
Fever
Headache
Pain in the throat or chest
Sleep disorders
Unspecified viral pneumonia
There is no standard clinical definition of post-acute sequelae of COVID-19, which complicates documentation and coding for long COVID-19, the report said.
Appropriate application of ICD-10-CM code U09.9 is a must as it will help public health professionals better understand and monitor post-COVID-19 conditions moving forward.
A workforce group penned a letter to HHS that highlights recommendations for meeting the legislation's deadlines.
The Workgroup for Electronic Data Interchange (WEDI) advisory group recently penned a letter outlining six ways HHS can work closely with standards development organizations and other healthcare partners to identify and pilot test appropriate No Surprises Act standards, harmonize them with existing and forthcoming standards and workflows, and more.
The No Surprises Act, which became effective January 1, contains provisions that protect patients from surprise medical billing and out-of-network emergency care costs not reimbursed by insurance.
Although considered a win for patients, the law (and its many nuances) have put a huge strain on organizations and their revenue cycle staff.
While WEDI strongly supports the overall goals of the No Surprises Act, the group says it has significant concerns regarding how the good faith estimate (GFE), GFE convening provider/facility provision, and advanced explanation of benefits (AEOB) requirements can be implemented by the healthcare industry.
The group says that with no established standards and automated workflows, providers and facilities will face challenges identifying who the convening provider/facility should be, who the appropriate co-providers/facilities should be, how to collect GFEs from these coproviders/facilities, and how to transmit GFEs to the patient’s health plan.
"Health plans will experience difficulties in collecting the GFE information necessary to produce the AEOB from providers and facilities and communicating to providers and facilities when GFE information is missing. All stakeholders will face hurdles meeting the legislation's deadlines to get GFEs and AEOBs to the patient," the group's letter states.
To address these challenges, WEDI has made the following six recommendations for HHS to consider:
Extend the enforcement discretion for the convening provider/facility provision of the Act.
Identify appropriate No Surprises Act GFE and AEOB data exchange standards and automated workflows for providers, facilities, and health plans.
Harmonize No Surprises Act GFE and AEOB data exchange standards with current and forthcoming administrative transactions.
Adopt No Surprises Act GFE and AEOB data exchange standards only after they have been pilot tested by appropriate industry stakeholders.
Employ a staged approach to meeting the data exchange requirements of the act until standards have been fully adopted by the industry.
Work with industry partners to educate patients and industry stakeholders on the No Surprises Act opportunities and requirements.
The group says it looks forward to a continued partnership with the federal government and offering assistance in the development and implementation of an appropriate No Surprises Act pathway.
