The AAO addresses prior authorization processes that the group says delay care.
In recent comments to CMS, the American Academy of Ophthalmology (AAO) addressed CMS’ proposed rule regarding improving the electronic exchange of healthcare data, particularly in terms of addressing Medicare Advantage prior authorization processes, an area of the rule that the group says has a profound effect on patients.
According to the March 13 letter that the organization shared with HealthLeaders, the AAO says it has been forcefully advocating for ophthalmologists and their patients who have been subjected to sweeping prior authorization policies delaying cataract surgeries, particularly imposed by Medicare Advantage plans.
In the letter, the AAO called for four actions from CMS:
Ensuring accountability through enforcement of decision deadlines and public reporting of denial metrics.
Avoiding potential administrative burden for provider practices by removing the unnecessary Merit-Based Incentive Payment System Promoting Interoperability measure proposal.
Adding protections for small and rural practices.
Expanding application of the rule’s provision to address other key areas of concern, such as health equity, step therapy, and Digital Imaging and Communications in Medicine standards.
Additionally, the AAO expressed concern that CMS is soliciting comments on the “approach to prior authorization within the Rule that could be applicable under Medicare fee-for-service.”
In a comment sent to HealthLeaders, the AAO noted that while the group supports CMS’ actions trying to simplify prior authorization processes, the AAO is concerned by the solicitation for comments on if and how the approach to prior authorization could be applicable under the Medicare fee-for-service payment model.
“We ardently oppose prior authorization under Medicare fee-for-service and urge CMS to suspend any existing prior authorization policies on services not mandated by legislation. We believe that prior authorization expansion in fee-for-service has the potential to harm Medicare patients’ access to necessary care and should not move forward without a specific legislative mandate,” the AAO said.
In an industry inundated with technology, how can it be used to counter patient burnout in the revenue cycle and beyond?
When revenue cycle leaders look to ease financial burdens for their organization, there is one area that can’t be overlooked: the patients.
From the patient financial experience to the clinical experience, keeping patients happy and avoiding burnout is necessary for a thriving organization. Not only can burnout negatively impact patient experience and the quality of care they receive, patient burnout can also lead to decreased patient volume and revenue for healthcare organizations.
When it comes to technology, what can be done to remedy the patient experience and avoid burnout and lost revenue?
Sidd Shah, vice president for product and business growth at Healow Health and former program lead for the New York City Health Department’s Primary Care Information Project, has seen the burnout problem up close, and recently shared his thoughts with our sister publication Part B News on how to counter patient burnout through tech and more.
Patient burnout, Shah said, isn’t just caused by the patient’s experiences at the organization; it could grow from related extrinsic anxieties, such as economic factors that the patient may relate to their ability to access care. “Or it could be about just finding the right physician opinion,” Shah said, “or taking too long to find an appointment, or the provider not being empathetic about the patient not being able to pay their medical bills.”
Expectedly, Shah suggests a role for technical solutions—for example, a “direct booking” solution for scheduling. This would prevent the confusion of competing appointment streams, he said, where “you as a consumer go to something-dot-com or to your app, and when you book you're not looking at the same schedule as the provider, and some other patient might be on the phone or on another site booking an appointment.”
Shah is also a fan of patient self-check-in: “It instills a sense of control and removes [the] paper process of filling [out] forms,” he says. It also “gives providers more time to spend with patients vs. on systems and data entry.”
Timely messaging to the patients on the day of or day prior to a pre-scheduled appointment is another way to enhance the patient experience, Shah said. “Televisits between in-person visits if schedules are heavily booked [so] patients are not waiting too long to be seen” is also a way to use tech to ease stress that can lead to patient burnout, Shah said.
The American Medical Association (AMA) recently detailed coding changes for evaluation and management reporting.
There are yet-to-be-released evaluation and management (E/M) changes on the way in 2024 and 2025, according to the CPT Editorial Summary of Panel Actions, which the AMA also published earlier this month.
But for now, there are many recent changes to this code set that your outpatient coding teams should be aware of.
As revenue cycle leaders know, coding challenges can easily lead to delays in reimbursement. When the coding process is hindered, the revenue cycle can be slowed by a backlog of charts, errors in claims, or working denials, which is why staying up to date on even the most minute changes is essential.
When it comes to recent updates, there are two small but important changes (in bold below) in the 2023 CPT Manual section “Amount and/or Complexity of Data to be Reviewed and Analyzed:”
Independent interpretation: The interpretation of a test for which there is a CPT code, and an interpretation or report is customary. This does not apply when the physician or other qualified healthcare professional who reports the E/M service is reporting or has previously reported the test. A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test. A test that is ordered and independently interpreted may count both as a test ordered and interpreted.
Appropriate source: For the purpose of the discussion of management data element (see Table 1, Levels of MDM), an appropriate source includes professionals who are not healthcare professionals but may be involved in the management of the patient (e.g., lawyer, parole officer, case manager, teacher). It does not include discussion with family or informal caregivers. For the purpose of documents reviewed, documents from an appropriate source may be counted.
“The most recent CPT errata’s clarification regarding the counting of data elements is a bit surprising,” Shannon McCall, director of HIM and coding at HCPro, told Part B News.
According to Part B News, allowing the order of a unique test and the independent interpretation of that same test to be counted separately could make it easier to classify data complexity as moderate for many encounters in the inpatient, observation, and emergency department (ED) settings.
“In EDs, especially after hours, it is not uncommon for multiple tests (imaging, labs, etc.) to be ordered and those orders may very well include ones that are eligible for independent interpretation,” McCall said.
Coders should remember that “To classify overall MDM, another of the two elements (number and complexity of problems addressed or risk of morbidity) must also be met,” McCall adds, “It would seem quite easy for EDs, since prescription drug management is likely a component of the services provided for many patients.”
This could increase reporting of ED codes 99284 (ED visit for the E/M of a patient, which requires a medically appropriate history and/or examination and moderate level of MDM) and 99285 (ED visit for the E/M of a patient, which requires a medically appropriate history and/or examination and high level of MDM), McCall said in the interview.
Compliance was based on the inclusion of machine-readable files for all items and services, as well as price display of the 300 most common shoppable services. The newest findings reveal a modest increase in compliance percentage since the previous report in August 2022, with 24.5% of hospitals (489) now compliant, compared to 16% last year.
One system that took one of the top spots in compliance was Lifepoint Health. According to the report, 73% of hospitals owned by Lifepoint Health were found to be in compliance with the price transparency law.
So how is the system working to perfect its price transparency adherence? HealthLeaders met up with Tina Barsallo, vice president of revenue cycle operations at Lifepoint Health, to chat about the health systems’ strategies.
HealthLeaders: Congratulations on achieving high marks in adherence! What was the process like for Lifepoint in adhering to price transparency requirements?
Tina Barsallo: We created an internal pricing transparency team in the year prior to the regulation’s effective date. Team members included revenue cycle operations, revenue cycle analytics, compliance, managed care, legal, and project management. Other team members were brought in as needed, such as our facility revenue cycle management leaders and CFOs.
The pricing transparency team evaluated the requirements thoroughly and outlined the proper path for Lifepoint, and then executed on each aspect to ensure the requirements were met. The team continues to meet regularly to confirm there have been no changes to the requirements, and the revenue cycle team handles on-going monitoring of the websites and links, as well as the annual refresh.
HealthLeaders: Even before the creation of your internal pricing transparency team, did you have any pre-existing processes in place, or did you have to create all new processes from scratch?
Barsallo: Prior to the rule, Lifepoint provided estimates to patients as a standard practice. Our internal tool was used as a model to develop the patient-friendly tool published on our websites for the shoppable services. The machine-readable file was newly developed from scratch, and we have worked to automate this file as much as possible.
HealthLeaders: What advice do you have for other revenue cycle leaders looking to shore up their price transparency efforts?
Barsallo: If possible, pull a team together to create joint ownership and partnership in creation of the tools and to help drive consistency and compliance. Reach out to peers to brainstorm on ways they have accomplished compliance, so you don’t need to reinvent the wheel. It is extremely helpful to collaborate with other providers and health systems. Both paths were two key activities and steps taken by Lifepoint.
Multiple medical associations respond to a request for information on workforce shortages and solutions.
The Senate Health, Education, Labor, and Pensions Committee recently published a request for information on the drivers of healthcare workforce shortages and potential solutions. The request garnered responses from several large medical associations with solutions aimed at prior authorization requirement reduction and more support in automation.
When it comes to prior authorizations, the MGMA said in its feedback that in order to address the multi-faceted causes of physician and staff burnout, Congress should examine legislative solutions to ease administrative burden and allow providers to focus on patient care, including prior authorization reform.
“MGMA urges the committee to support the next version of the Improving Seniors’ Timely Access to Care Act and work to reduce prior authorization requirements that MGMA members consistently say are the most burdensome they face every year,” the MGMA said in a statement sent to HealthLeaders.
Providers frequently experience staffing-related issues specific to the prior authorization process, and physicians are required to devote time and resources that should be spent on patient care, the group says.
Also speaking out is the American Hospital Association (AHA).
In its letter the AHA said “long-building structural changes within the healthcare workforce, combined with the profound toll of the COVID-19 pandemic, have left hospitals and health systems facing a national staffing emergency.”
One way to help? Better support the use of automation and artificial intelligence, the AHA said.
While automation is a mainstay in many sectors of the revenue cycle already, the clinical team can benefit as well.
“Hospitals and health systems are exploring the use of technology by automating certain kinds of clinical documentation, using artificial intelligence to help consolidate and trend large amounts of clinical information to provide insights for delivering care,” the AHA said in its letter.
While the AHA notes that technology cannot substitute for caregivers, it can enhance their ability to practice efficiently and reduce burden, it says. Because of this, Congress should consider providing support for the pilot testing of innovative technology solutions that support the healthcare workforce, the group says.
Organizations will soon be seeing their IDR payment determinations.
CMS just announced that certified independent dispute resolution (IDR) entities must resume making payment determinations for disputes involving items or services furnished on or after October 25, 2022.
In the same announcement, CMS said that starting last week, disputing parties will begin receiving a majority of their payment determination notices from the IDR portal.
At the time, the American College of Emergency Physicians, the American College of Radiology, and the American Society of Anesthesiologists urged CMS to quickly resume all IDR payment determinations paused by its February order.
Following a court decision that vacated nationwide the federal government’s revised IDR process, in early February CMS instructed certified IDR entities to hold all payment determinations until the departments issued further guidance.
While CMS provided some relief at the end of February when it instructed certified IDR entities to resume making determinations for payment disputes involving services provided before October 25, the associations called on the agency to resume swift determinations for disputes after that date too.
Preventing denials, implementing automation, and bridging departmental gaps are just some of the tasks these revenue cycle executives are leading out at their organizations.
Gender equality in the healthcare C-suite hasn't yet been attained—a recent study showed only 33% of senior leaders in healthcare are women—but there are many women executives that are bringing strong strategic leadership to their revenue cycles every day.
In an attempt to underscore those underrepresented, HealthLeaders has chosen four revenue cycle leaders worth highlighting for their achievements in preventing denials, implementing automation, and bridging departmental gaps in the revenue cycle.
Stacy Reck, director of CDI/utilization review at Avera Health
In most revenue cycles, the clinical documentation integrity (CDI) staff is responsible for reviewing documentation to ensure that it supports reported diagnoses and for collaborating with staff to update documentation that is insufficiently supporting medical necessity.
Because your CDI teams have such a heavy hand in documentation review, they make it the perfect place to start when shoring up clinical validation denials.
Reck has streamlined multiple strategies for preventing clinical validation denials before they happen. Reck has also led her team at Avera Health on initiatives that helped to lower MS-DRG downgrades and financial takebacks.
Christy Pehanich, AVP of revenue cycle management at Geisinger Health System
Most revenue cycle leaders have started implementing automation in one sector or another of their department, but while automation may seem like a simple fix, collaboration is usually needed with teams beyond the revenue cycle.
More leaders are bringing in their IT teams to help streamline their revenue cycle automation, and just as Pehanich has done at Geisinger, successfully collaborating with IT and merging skill sets is a necessity in optimizing revenue cycle automation.
Melissa Woods, assistant vice president of revenue cycle financial clearance at Ochsner Health
It's clear that operationalizing processes to generate reliable, accurate good faith estimates (GFE) is necessary and has pushed many organizations to enhance their technology to ease this burden for their front-end revenue cycle.
Woods has done just that at Ochsner by looking internally at their preexisting software while filling in any gaps with a third-party vendor. She played a large role in, what she calls, the organization's “hybrid approach” to its GFE technology implementation.
Tami McMasters Gomez, director of coding and CDI services at UC Davis Health
It was a priority for McMasters Gomez to implement the best technology for her CDI and physician teams to improve their workflows and ensure maximum reimbursement for the organization's middle revenue cycle.
Since implementing new technologies for CDI and physician teams, with the help of McMasters Gomez, UC Davis has seen an overall improvement of physician workflows, improved documentation accuracy, and an almost 5% increase in comorbidity capture rates.
The Director of Revenue Recovery at Memorial Hermann Healthcare System talks through perfecting patient billing processes and what’s in store for the future.
Revenue cycle leaders are in search of ways to better secure revenue by bolstering their technology and streamlining processes, and if perfecting the patient billing experience isn’t on the radar, a big opportunity could be missed.
Patients care about the billing experience—so much so that 56% of respondents in a recent survey said they would switch providers if the experience was poor.
In addition, the study showed that personalization and consistency were regarded as important to the billing and payment experience. Personalization was very important to 42% of respondents and somewhat important to 41%, while consistency was regarded as very important to 59%.
It’s obvious that patients are more likely to be satisfied with their healthcare experience if the billing process is transparent, accurate, and efficient. And while patient satisfaction is reason enough to optimize the billing and payment experience, a streamlined billing process leads to faster and more accurate reimbursement and improved cash flow.
So how can revenue cycle leaders perfect their billing processes?
Tonie Bayman, director of revenue recovery at Memorial Hermann Healthcare System, said during the Patient Financial Experience NOW Summit that honing patient billing processes on the front end is creating greater patient financial satisfaction at her organization.
“We have a new tool that we’ve recently started using to measure satisfaction, and we can see the comments about what has happened prior to service,” she says. “While we aren’t at the bedside treating somebody clinically, what we do matters in relieving the anxiety.”
Another area revenue cycle leaders can look to create a positive financial experience: financial clearance, Bayman says.
Based on focus group data, Memorial Hermann is working on an additional offering to grant patient financial clearance to some patients before they are scheduled for service to help them on their financial journey. “Patients have told us they want to know that everything’s taken care of…and that they have an authorization before they ever schedule the appointment.”
Bayman says that the industry will likely see more vendor consolidation in the next five years as providers invest even more time and resources into improving patient payment processes.
“[Revenue cycle leaders] have a lot to manage now, and it’s better for them if they can pair down to one or two vendors,” she says. “There’s going to be more consolidation and newer technology that’s going to help manage some of this complexity,” says Bayman.
By making meaningful and intentional changes to the patient billing experience, providers can ensure the financial journey leaves a positive lasting impression on patients, families, and caregivers.
"The proposed changes (Model V28) would make significant changes to the existing V24. V24 was structured using the ICD-9-CM codes and, although translated to ICD-10-CM, did not provide the granularity we are now able to with code assignment," Laurie Prescott, interim director for ACDIS and director of CDI education for HCPro, said in a recent issue of CDI Strategies.
This change means that more specificity in code assignment will be required in a number of condition categories, upping the administrative burden on certain revenue cycle staff.
The proposal increases the number of payment-HCCs by 29, with a total of 115 payment HCCs.
"These 115 HCCs have been renumbered, and new names have been applied to many groupings. Within the methodology, 268 new codes have been identified, but in total V28 demonstrates a reduction of 2,027 diagnoses codes that provide risk adjustment within the present version," Prescott wrote.
Major medical groups are now responding and taking aim at the short comment period, which was scheduled to end the first week in March.
According to AMGA, the proposed changes to the risk adjustment model would adversely impact healthcare providers participating in value-based care contracts.
In addition, AMGA disagrees that removing codes from the HCC model addresses discretionary coding variation, but instead would remove distinct clinical differences from the model.
"CMS should not move forward with its proposed change until stakeholders understand what the impacts of these changes will mean to the Medicare Advantage plan design and care delivery, particularly to patients with chronic conditions such as diabetes and congestive heart failure," the AMGA said in a press release.
"Modifying the HCC model is not a simple technical update or revision," said AMGA President and CEO Jerry Penso. "It’s likely to have significant ramifications, affecting both plans and providers. CMS should recognize that stakeholders can’t provide substantive, constructive feedback in such a short timeframe."
If CMS’ proposals are finalized, Medicare Advantage plans must submit bids based on the new model by June 5.
Major medical associations demand CMS resume all disputed No Surprises Act payment determinations.
The American College of Emergency Physicians, the American College of Radiology, and the American Society of Anesthesiologists are urging CMS to quickly resume all independent dispute resolution (IDR) payment determinations paused by its February order.
While CMS provided some relief at the end of February when it instructed certified IDR entities to resume making determinations for payment disputes involving services provided before October 25, the associations are calling on the agency to resume swift determinations for disputes after that date too.
As background, CMS temporarily halted the IDR process payment determinations following last year’s district court ruling before they were again reinstated. The medical associations assert that the government’s pause exacerbates the existing backlog of IDR determinations, causing harm to healthcare providers who provided those services.
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