Leaders have started turning to technology to alleviate staffing shortages, but what can they do when implementing new technology isn't an immediate option?
Revenue cycle leaders have started turning to technology to fill gaps as staffing shortages seem to have hit a high. In fact, one in four finance leaders need to hire more than 20-plus employees to fully staff their revenue cycle departments.
But what can revenue cycle leaders do when implementing new technology isn't an immediate option?
For a short-staffed department, filling positions is a priority. But that's easier said than done in the current labor market. Attracting job candidates and selecting the right person for the job have always been challenges, but revenue cycle leaders are discovering that the pandemic has fundamentally changed what job seekers are looking for and what they're willing to compromise on.
Specifically, employees are looking for remote work, according to Stacey McCreery, MBA, and Julie Teixeira of ROI Search Group. On an episode of The Revenue Integrity Show: A NAHRI Podcast, McCreery and Teixeira discussed how the expansion of remote work has affected hiring and staff retention.
Although the initial transition to remote work challenged some, most employees quickly found the benefits outweighed the drawbacks, according to McCreery and Teixeira. In addition, some organizations discovered moving nonclinical departments off-site freed up valuable real estate on campus and reduced overhead costs.
Organizations that still expect to bring all staff back on-site on a full-time basis could find themselves at a disadvantage in the job market, McCreery and Teixeira said.
Organizations need to keep remote and flexible work options on the table to remain competitive. However, this can be a tough sell for senior leadership accustomed to traditional work arrangements and reluctant to commit to long-term changes.
"They want to see people in their seats, and they want to be able to walk around and see what they're doing," Geneva Schlabach, co-founder and CEO of VISPA, recently told the National Association of Healthcare Revenue Integrity (NAHRI). "I think it's going to have to be a progressive shift to allowing more of a hybrid workforce. "
A VISPA client initially resisted extending remote and hybrid work options, Schlabach says. However, as open positions went unfilled, they eventually settled on a hybrid work model that allowed them to remain competitive in the job market.
It's not an all-or-nothing scenario. If leaders remain flexible with work-from-home options, it reverberates through the culture and staff become more flexible in return, she says.
Leaders should lean into change when staffers depart, Schlabach says. Take a careful look at everything, from job duties to job titles, and consider what should stay as-is and what needs a refresh.
Perhaps a revenue cycle department had multiple levels of managers and directors and a complex hierarchy of staff involving tiers of team leads. Reevaluate the structure to determine whether this still make sense. If new workflows and priorities are developed, should old titles and job descriptions be grafted onto them without change?
"I believe that we are at a time within healthcare that we do have to relook at those titles," she says. "We may have had this corporate structure that was a lot more stringent at one time that we can maybe ease up on some of that and do things differently."
CMS recently announced the suspension of prior authorization requirements for specified orthoses prescribed and furnished urgently or under special circumstances.
Prior authorization requirements for specific durable medical equipment, prosthetics/orthotics, and supply codes will be suspended under certain circumstances, CMS announced.
CMS explains that due to the need for certain patients to receive an orthoses item that may otherwise be subject to prior authorization (such as when the two-day expedited review would delay care and risk the health or life of the beneficiary), it is suspending prior authorization requirements indefinitely for these services.
The recently published FAQ addresses questions related to the implementation of the No Surprises Act.
The Departments of Health and Human Services, Labor, and Treasury recently released a series of frequently asked questions (FAQ) related to the No Surprises Act.
The FAQs cover common questions including balance billing prohibitions, the application to plans without a network or with a closed network, and emergency services provided in a behavioral health crisis facility.
For example, one question asks if the surprise billing provisions of the No Surprises Act apply in the case of a group health plan or group or individual health insurance coverage that generally does not provide out-of-network coverage.
In this instance, the answer is yes. According to the FAQ, the No Surprises Act’s protections regarding emergency services, non-emergency services furnished by a nonparticipating provider with respect to a visit to a participating facility, and air ambulance services apply if those services are otherwise covered under the plan or coverage, even if the plan or coverage otherwise does not provide coverage for out-of-network items or services.
This FAQ comes on the heels of a new final rule and additional guidanceto further implement the independent dispute resolution process and require payers to provide additional information to providers about the qualifying payment amount.
Insurers may be calculating median in-network rates for specialty services using contracted rates for services that were never negotiated, study says.
In possible violation of the No Surprises Act, health insurance company calculations of qualified payment amounts (QPA) for anesthesiology, emergency medicine, and radiology services likely include rates from primary care provider (PCP) contracts,a new study says.
The study conducted by Avalere Health and commissioned by three national physician organizations examined a subpopulation of PCPs and determined that contracting practices may directly impact the QPA.
"Despite the law's directive that QPA calculation be based on payment data from the 'same or similar specialty' in the same geographic region, insurers may be calculating median in-network rates for specialty services using PCP contracted rates for services that were never negotiated, may never be provided by those physicians, and may never be paid," the study said.
This method may violate the No Surprises Act law and produce insurer-calculated QPAs that do not represent typical payments for these services, the study said.
In the study, 75 primary care practice employees who have a role in contracting with insurers were surveyed regarding whether they contract with insurers for services they rarely or never provide, as well as negotiation practices related to these services.
68% of respondents had services that they rarely provide (fewer than twice a year) included in their contracts, and 57% of respondents had services that they never provide included in their contract, the survey found.
"This new research raises significant questions about the accuracy of insurer calculated QPAs," said American Society of Anesthesiologists President Randall M. Clark, MD, FASA. "We have received reports of extremely low QPAs that bear absolutely no resemblance to actual in-network rates in the geographic area; yet these same rates are being used by insurers as their initial payment."
The American Society of Anesthesiologists, the American College of Emergency Physicians, and the American College of Radiology are calling on policymakers to eliminate the QPA as the main factor in arbitration and ensure the integrity of the QPA by insisting they be calculated based on "same or similar specialty" in-network rates.
This would mitigate "the unintended consequences of relying on health insurers' median in-network rates based partially on data from providers who don’t actively negotiate those rates," said Gillian Schmitz, MD, FACEP, president of the American College of Emergency Physicians. "Physicians rely on fair reimbursement to keep their doors open and continue providing lifesaving medical care to their patients."
Ongoing hurdles in scheduling, reimbursement, and collections compound difficulties for a healthcare industry already under stress a recent study says.
Medical Group Management Association (MGMA) recently released a report detailing new benchmarks related to the adoption rate of value-based reimbursement and other hurdles revenue cycles frequently face.
The report found that the average rate of value-based care only accounts for approximately 5.5% to 14.74% of revenue, with primary care and surgical specialties reporting lower revenue shares from value-based contracts in 2021 and nonsurgical specialties attributing 14.74% of total medical revenue to value-based contracts, the report said.
Other aspects of the revenue cycle were also studied in the report.
According to the MGMA, the return of patient volume in 2021 led to shifts in appointment scheduling benchmarks, as higher demand for care saw no-show rates hold steady and an uptick in cancellation rates which has put a large burden on revenue cycle staff.
Overall patient portal usage improved from 2020 to 2021, with a significant increase in patient logins, the MGMA found.
The study also found that increased care volumes, claim denials, and staffing shortages combined to spur concerning shifts in billing and collections benchmarks, as copay collections at time of service declined and charge-posting lag times increased for specialist practices.
Also, the percentage of claims denied on the first submission doubled across primary care, nonsurgical, and surgical specialties, the study noted.
“The medical workforce is grappling with burnout, staffing declines, decades-high inflation, operational challenges and a dynamic reimbursement environment that affects providers across the board,” said Dr. Halee Fischer-Wright, MD, MMM, FAAP, FACMPE, president and chief executive officer of MGMA.
“This report reveals how addressing scheduling errors and billing denials could help relieve the financial burden on health groups, moving them toward value-based care that promotes the welfare of physicians, staff, and patients.”
The report includes data from more than 2,300 organizations across multiple specialties and practice types.
While some organizations already have systems in place to adhere to price transparency requirements, opportunities still exist to adjust outdated revenue cycle processes.
The No Surprises Act, which became effective January 1, requires hospitals to post the prices for their most common procedures as well as offer a patient-friendly tool to help shop for 300 common services.
Unfortunately, most organizations are behind in adhering to this requirement—still.
Earlier this year,JAMA published a study that concluded that out of the 5,239 hospital websites evaluated, roughly 51% of hospitals did not adhere to either price transparency requirement.
Almost 14% of hospitals studied had a machine-readable file but no shoppable display, while 30% of hospitals had a shoppable display but not a machine-readable file, according to the study. It also found less than 6% of hospitals were compliant with both components of the mandate.
Of the hospitals studied, 5.1% were in total noncompliance as they did not post any standard charges file, and 51.3% failed compliance because the majority of their pricing data was missing or incomplete.
While some organizations now have systems in place to help them adhere to the new rules, opportunities still exist to revisit outdated revenue cycle processes to better comply with these regulations.
Connie Lockhart, director of strategy and operations at Impact Advisors, discussed with Healthleaders six key strategies that revenue cycle leaders can use to increase price transparency, mitigate the risk of surprise billing, and support efforts to improve the patient experience through enhanced revenue cycle processes.
Before diving into the six key strategies, when first shoring up price transparency processes (and as mentioned in the studies above), there are two main requirements that organizations need to adhere to immediately.
"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," she says. "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, revenue cycle leaders can then move to streamlining other areas of the requirement. Here are six key strategies Lockhart suggests.
Shore up your scheduling
Improve the patient experience with better access to scheduling appointments and verifying patient eligibility, Lockhart says.
For eligible self-pay patients, revenue cycle leaders should ensure timelines are in place for governance of the No Surprises Act. It is the provider’s responsibility to verify if the patient is self-pay, so looping in front-end revenue cycle staff to address this task is a must.
For example, if a patient schedules more than ten business days in advance of a service, an organization has three days to issue a good faith estimate. If a patient schedules three days out, staff only has one day to issue the estimate.
Refine those good faith estimates
Patients are consumers, Lockhart says, so it’s important to establish expectations regarding the process for collecting out of pocket expenses. A lot goes into good faith estimate requirements, so it's essential for revenue cycle leaders to stay up to date on those intricacies.
For example, for services provided in 2022, patients can dispute medical bills that are $400 or higher than the good faith estimate that was provided.
For self-pay patients who do not have health insurance or choose not to use it, the good faith estimate is applicable, Lockhart says.
Work on collection communication
Convert the good faith estimate into cash collections to make it a smoother process for both the patient and the organization, Lockhart says.
Implementing scripting, automation of a patient estimator tool, and training for all pre-service/registration staff is key to ensuring timely and consistent communication and collections.
Leverage price transparency to build patient trust
One positive aspect of price transparency for organizations is that it can help build trust by providing patients the cost of service prior to receiving services, Lockhart says.
In order to build this trust with patients, revenue cycle leaders must make sure processes are streamlines and compliant.
"Ensure compliance with pricing transparency and good faith estimates by utilizing the CMS requirements as a baseline to assist in your hospital's review of the hospital price transparency final rule and complete a gap analysis to identify processes/elements that are not aligned with the requirements," Lockhart says.
It's also essential that your chargemaster is easily accessible, and that revenue cycle leaders perform quality checks to include bill audits. Lockhart says this strategy will ensure there is timely, consistent, and accurate communication with the patient regarding the cost of care before both the service and the bill.
Being timely, consistent, and accurate in your price transparency and estimates will build that trust and ensure a positive patient financial experience.
Train staff on point of service collections
Educate and train revenue cycle staff to be able to clearly communicate and explain the good faith estimate to patients, Lockhart advises.
Including scripting and frequently-asked-question handouts will help front end staff better communicate with patients about these prices and bills.
Resolve patient cost share
Revenue cycle leaders can reduce denials and self-pay vendor costs by resolving patient cost share on the front end, Lockhart suggests.
To do so, it's important to implement governance and reporting for point of service collections, and to track and monitor point of service collections (e.g., expected vs. actual payments) on a monthly basis, Lockhart says.
CMS regulations and accompanying surprise billing updates are changing faster than revenue cycle leaders can keep up.
The surprise billing ban was put in place by CMS to protect patients from receiving unforeseen bills for out-of-network and emergency services after receiving treatment. While beneficial for patients, organizations have long shared their distain of the burden this causes for revenue cycle staff.
Revenue cycle leaders need to stay informed of this requirement in order to be compliant and ensure a positive patient financial experience. Review the most recent surprise billing stories from HealthLeaders.
A federal judge denied a New York doctor's lawsuit against the No Surprises Act, dismissing the request for a preliminary injunction and ruling that the law is constitutional.
U.S. District Judge Ann Donnelly rejected surgeon Daniel Haller's injunction to blow the law, which was filed on December 31, 2021, the day before the No Surprises Act took effect.
Haller and his private practice, which performs procedures on patients who are admitted after an emergency department visit, alleged in the complaint that the law is unconstitutional and deprives providers the right to be paid a reasonable payment for their services due to the independent dispute resolution process.
Several aspects of the surprise billing mandate went into effect on January 1 of this year, including federal protections against balance billing, uninsured and self-pay good faith estimate requirements (GFE), continuity of care protections, and provider directory requirements.
While the policies have been beneficial for patients, MGMA says the requirements have created administrative burden for providers as the interim final rules were published with minimal time before implementation.
The workgroup takes aim at the GFE convening provider/facility provision saying it has significant concerns with how this part of the act can be successfully adopted by two providers.
In the letter, WEDI recommends HHS consider an initial phase of the GFE requirement initiated by a patient request, extend the enforcement discretion period, identify standards-based solutions, and phase in the one- and three-day time requirement.
WEDI says these issues should be expeditiously addressed by HHS to ensure successful implementation of the legislative provisions of the act.
"While the No Surprises Act includes much needed consumer protections against catastrophic 'surprise' bills, it also includes challenging data exchange provisions such as the convening provider/facility requirement," stated Charles Stellar, WEDI president and CEO.
Yet 20% of respondents in the Morning Consult survey say they or their family have been charged unexpectedly, with another one in five billed after being treated by an out-of-network provider at an in-network facility.
The bills have been especially costly in some cases, as 22% of respondents say their charges were over $1,000.
Unexpected charges haven't just been an issue after the fact. The survey found about one in four adults delayed or skipped medical care because they were concerned with receiving a surprise bill. Emergency room care suffered the most in this facet, with 14% of respondents saying they did not seek care, while another 14% say they hesitated but ended up receiving care.
As organizations clamber to adhere to price transparency requirements, nearly half of patients have never heard of it.
Healthcare organizations' low compliance with price transparency has been in the spotlight as of late, but an even more concerning statistic comes from the patients: Nearly half (49%) of US consumers have not heard of the price transparency rule at all, according to the recent survey from Cedar.
Conversations around price transparency are commonplace among healthcare professionals, but while 49% of those surveyed have not heard of the price transparency rule, of those who are familiar with it, nearly a quarter (24%) don’t understand it.
Price transparency has yet to move the needle for patients for a variety of reasons, with low compliance and lack of centralized data just to name a few, Cedar told Healthleaders.
But with nearly 90% of consumers having compared the costs of two items while shopping, the survey said, it's clear that organizations need to give patients what they inherently want: the ability to easily price shop and compare costs when seeking healthcare.
As the patient financial experience is top of mind for revenue cycle leaders, now is the time to act. According to the survey, 74% of respondents said they wish their hospital better explained its price transparency compliance to them.
On top of this, 77% of consumers said they would price compare two hospitals prior to receiving care at a hospital if that information was available. 71% of consumers consider price transparency and costs when choosing where they go for medical care, the survey said.
So, what can revenue cycle leaders do to help educate their patients regarding price transparency? Florian Otto, CEO and co-founder at Cedar, spoke exclusively to HealthLeaders on this.
"There are many ways in which revenue cycle leaders can help educate their patients regarding price transparency, including leveraging technology to create a digital front door that prioritizes the consumer experience," Otto said.
"By offering personalized care information, consumers can engage with valuable, user-friendly price transparency data before their visit, and this way providers can ensure there is alignment on payment responsibility before a bill is sent."
The market is anticipated to increase at a compound annual growth rate of 16% from 2022-2032, and by the end of 2032, medical billing outsourcing is expected to reach a valuation of $55.6 billion, the report said.
The report explained that the pandemic has highlighted the significance of adopting proactive actions and establishing a strong, collaborative, and reactive digital healthcare infrastructure.
"As a result, in order to enhance market development, numerous organizations are adopting methods such as digitization and outsourcing of all non-core areas of their operations, such as invoicing and accounting. The rapid move to digital billing is directly related to the growing demand for the medical billing outsourcing market," it said.
This information comes amid reports of high medical billing costs and staffing shortages for the revenue cycle.
According to the study, although most countries use ICD-10, the U.S. has a very different coding process from other countries which is driving up medical billing costs.
On top of high billing costs, workforce shortages have been a major challenge for healthcare leaders and the revenue cycle in particular is in serious need of staffing.
Leaders at Hutchinson Clinic knew they had to keep patient experience in the forefront in order to ensure the success of their revenue cycle.
An important aspect to optimizing the revenue cycle for leaders at Hutchinson Clinic in Hutchinson, Kansas, is the ability to find which methods worked the best for the organization internally, while still working to improve the patient experience.
The clinic has a team of roughly 60 in-house revenue cycle management employees who needed onboarding and training before all processes could be improved. At the same time, Mike Heck, CEO, was adamant that this process didn't disrupt continuity of care for the patients stretched across Hutchinson's large geographic footprint.
"The beauty of working with a partner for onboarding and training is that they're handing all of the heavy lifting behind the scenes, enabling us to focus on patient engagement, provider recruitment, and retention," Heck said. "We've recently seen a positive response from the community as a result."
Being that Hutchinson Clinic is the primary source of care for those in Reno County, it's imperative that patient engagement is at the head.
"We see quality care and patient satisfaction as our number one responsibility," Heck said. "Having a stable revenue cycle management ensures that bills are getting out the door and payments are being made, which frees our team up to focus on other areas."
Echoed Dashun Monk, CFO, "I have peace of mind knowing that our revenue cycle, specifically the coding, accounts receivable, and posting components are happening correctly and in an efficient manner."
.jpg)
.jpg)
