The AMA and CMS recently released new procedure codes for both your inpatient and outpatient coding teams.
As revenue cycle leaders work hard to avoid denials, payers won’t be afraid to deny your claims for coding errors. Keeping your directors and managers up to date on coding changes is key for proper and timely reimbursement.
For example, new codes will be added for aortic occlusions, spinal destruction procedures, and bone marrow transfusions. Several codes will also be added for the administration of newly developed immunizations.
Around the same time, the AMA’s CPT editorial panel released 20 new CPT codes. These new codes, along with two revisions, are mainly for cardiovascular procedures. These CPT codes will take effect July 1 and will be published in the 2024 CPT Manual.
Most of the new CPT codes pertain to cardiovascular procedures, such as percutaneous transcatheter thermal ablation of nerves, implantation and removal of a dual-chamber leadless pacemaker, and implantation of a superior and inferior vena cava prosthetic valve.
Elizabeth Ward, the CFO for Tidelands Health, a South Carolina-based healthcare provider with over $300 million in total revenue—agrees on the importance of proper documentation capture in the revenue cycle.
“[Something that I’ve helped my teams understand is] the importance of documentation and how that documentation is translated into codes that allows us to be paid for our services and care,” Ward previously told HealthLeaders.
“If you're documenting and coding well, it not only helps to get paid for what you do, but it also helps in your quality scores, and how you're looked at as a physician by CMS and other payers,” she said.
Because coding occurs mid-cycle, it provides an opportunity to catch errors introduced earlier in the process, as well as preventing similar errors in the future.
118 leading medical societies united to defend proposed prior authorization reforms.
The organizations, spanning from the American Medical Association to The Alaska State Medical Association, sent a letter to CMS urging it to finalize proposed prior authorization reforms that target the inappropriate use of authorization requirements by Medicare Advantage plans which, the organizations say, delay, deny, and disrupt the provision of medically necessary care to patients.
"Physicians appreciate the efforts of CMS to address the significant and multifaceted challenges that prior authorization requirements pose to Medicare beneficiaries and physicians," said American Medical Association President Jack Resneck Jr, in a recent press release.
"We applaud CMS for listening to physicians, patients, federal inspectors, and many other stakeholders, and recognizing a vital need to rein in Medicare Advantage plans from placing excessive and unnecessary administrative obstacles between patients and evidence-based treatments," Resneck said.
According to the letter, reforms proposed by CMS must be implemented amid mounting evidence that Medicare Advantage plans are delaying or even preventing Medicare beneficiaries from getting optimal care, resulting in alarming effects on patient health.
Because of this reason and more, the MGMA told HealthLeaders that the organizations have four key asks of CMS:
Finalize many of the prior authorization proposals in this rule that address long-established concerns
Apply the proposed clinical validity and transparency of coverage criteria policies beyond the current scope to include prescription drugs
Establish and implement an oversight plan that will hold plans accountable for noncompliance
Include additional prior authorization reforms in future rulemaking, such as eliminating step therapy, requiring gold-carding programs, and exempting medical groups participating in value-based models from prior authorization requirements
In the letter, the organizations pointed to three studies highlighting the prior authorization burden. According to the letter:
A recent survey found more than nine in 10 physicians (93%) reported care delays while waiting for health insurers to authorize necessary care. More than four in five physicians (82%) said patients abandon treatment due to authorization struggles with health insurers, and more than one-third (34%) of physicians reported that prior authorization led to a serious adverse event, such as hospitalization, disability, or even death, for a patient in their care.
The OIG found that Medicare Advantage plans improperly applied Medicare coverage rules to deny 13% of prior authorization requests and 18% of payments, in some cases ignoring prior authorizations or other documentation necessary to support the payment.
A Kaiser Family Foundation analysis found Medicare Advantage plans denied two million prior authorization requests in whole or in part, representing about 6% of the 35 million requests submitted in 2021. While about 11% of denials were appealed, the vast majority (82%) of appealed denials were fully or partially overturned, raising serious concerns about the appropriateness of many of the initial denials.
Building on that proposed rule, CMS released another proposal to strengthen prior authorization protections for patients, requiring: a granted prior authorization approval remain valid for an enrollee's entire course of treatment; Medicare Advantage plans to annually review utilization management policies; and coverage determinations to be reviewed by professionals with relevant expertise.
"Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health," said Resneck. "To protect patient-centered care for the 28 million older American that rely on Medicare Advantage, physicians urge CMS to finalize the proposed policy changes and strengthen its prior authorization reform effort by extending its proposals to prescription drugs. We stand ready to continue our work with federal officials to remove obstacles and burdens that interfere with patient care."
The HealthLeaders' Revenue Cycle Exchange is underway this week in Carlsbad, California.
Payer compliance and workforce are top of mind for the executives attending this week's HealthLeaders Revenue Cycle Exchange. As regulatory burdens and staffing shortages put strains on their revenue cycles, leaders agree they need to start thinking outside the box and working together.
When it comes to payer compliance, the leaders at the event say there are two major players that cause the most headaches for them: United Healthcare and Blue Cross Blue Shield.
When deciding how to work with these payers, there are a few strategies the leaders shared that work for them.
"Blue Cross always asks us to pull medical records. We don’t have the capacity to do it ourselves, so we requested that they send a representative down to do it themselves. And they did," Jeanne Stokes, CBO Manager at Ironwood Cancer and Research Centers, said.
While working with payers has been the biggest headache discussed so far, Christine Migliaro, vice president, revenue cycle operations at Northwell Health, reminded everyone that between payers, patients, and our own coworkers, "what makes our job complicated is what makes our jobs great.”
On the same note, Migliaro discussed in depth the importance of building a strong revenue cycle team when workforce challenges seem to be at their peak. "Your culture can’t be fake, it needs to be who you are," she says.
Even more important than a positive, honest culture is collaboration across the entire team. "I played many sports growing up, and they all prepared me for my current role because revenue cycle is the ultimate team sport," Migliaro said.
"We have 8,000 end users in our revenue cycle that do not report to us, and everything they do affects me. Partnership is really needed to get something done,” Migliaro said.
Discussion sessions were also held that focused on robust conversations about the No Surprises Act, including price transparency and good-faith estimates, and improving the patient financial experience.
Stay-tuned for more coverage of this event which will include “ideas presentations” from prominent leaders such as Michael Gottesman, assistant VP of revenue cycle at Northwell Health, and Allyson Keller, executive director at Piedmont Healthcare.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
Join us for the next HealthLeaders Revenue Cycle Exchange!To inquire about attending a HealthLeaders Exchange event, email us at exchange@healthleadersmedia.com.
If you experienced a recent surge of denials for observation visits, a payer error could be at fault.
Four Medicare administrative contractors (MAC) have announced that they improperly denied claims for hospital inpatient and observation care codes and are working on the problem, according to Part B News.
The error affects claims for observation visits performed on or after January 1 and is triggered by the place of service (POS) on the claim.
According to Part B News, First Coast Service Options and Novitas are working on an error that denies claims for initial and subsequent hospital visits reported with the POS for services in the on campus-outpatient hospital setting.
Palmetto GBA and WPS Government Health Administrators identified a similar problem with a wider impact. Their systems denied claims for discharge day management services in addition to initial and subsequent hospital visits, and off campus-outpatient hospital, emergency room, and comprehensive outpatient rehabilitation facility visits.
Don’t resubmit claims for improperly denied observation services to these MACs, Part B News warned. According to the announcements issued to date, the MAC will automatically adjust claims affected by the problem, so no revenue cycle action is necessary.
If your revenue cycle team resubmits the claims, it could trigger duplicate claim denials or improper payments.
More and more studies are pointing to the growing concern of denials for revenue cycle leaders as more pressure is put on these leaders to help increase their bottom lines.
Revenue cycle leaders must ensure their teams monitor denials of all types. Regularly monitoring denials helps revenue cycle leaders and their teams identify common reasons for rejections, develop solutions to prevent them, and ensure timely reimbursement.
The director of CDI/utilization review at Avera Health reviews two key areas needed to shore up clinical validation denials.
Denials management has become a major area of concentration for revenue cycle leaders.
In fact, denials rose to 11% of all claims last year, up nearly 8% from 2021. That 11% rate translates into 110,000 unpaid claims for an average-sized health system, according to the report.
While prior-authorization denials were at the heart of the cost increase in that study, there’s another area revenue cycle leaders should place their focus to help ease the denials burden: clinical validation denials.
Clinical validity denials occur when there is a lack of clinical evidence in the patient chart to support a billed diagnosis. Claims may be denied, for example, if they lack clinical criteria necessary to support a diagnosis, contain inconsistencies, or do not meet payer-specific diagnostic criteria.
In most revenue cycles, the CDI staff is responsible for reviewing documentation to ensure that it supports reported diagnoses and for collaborating with staff to update documentation that is insufficient to support 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.
Stacy Reck, director of CDI/utilization review at Avera Health, recently shared strategies for helping to prevent these denials before they happen and how to manage MS-DRG downgrades and financial takebacks.
A key defensive strategy for preventing denials is provider education, Reck said in a recent HCPro webinar. This can involve bringing data on the financial impact of documentation inconsistencies to providers and explaining how they can be prevented.
For example, Avera Health tracked and analyzed claims for acute respiratory failure that were denied due to a lack of explicit documentation of symptoms to support medical necessity. “If the patient has acute respiratory failure, you can’t only use phrases such as ‘patient resting comfortably.’ The patient may be resting comfortably for a period, but this doesn’t support a diagnosis of respiratory failure.”
In this instance, the CDI staff were able to effectively reduced denial rates for respiratory failure and other similar diagnoses by educating providers on the effective use of key clinical terminology to clearly explain the patient’s current health status.
“Clinicians want to document better and don’t want to get a query,” said Reck. “They may also have their own ideas for preventing documentation inconsistencies such as incorporating prompts into their EMR [electronic medical record].”
Making sure your middle revenue cycle leaders collaborate and continue to be educated on regulatory changes will help to improve on these denials before they happen.
But what if these denials still happen?
It’s essential for revenue cycle leaders to understand that these denials are even happening outside of the claims process and after payment, usually through MS-DRG downgrades, Reck told HealthLeaders.
Pictured: Stacy Reck, director of CDI/utilization review at Avera Health. Photo courtesy of LinkedIn
“These financial takebacks are often occurring under the radar because the business office staff doesn’t know about the denial because the account is at a $0 balance,” Reck says.
Collaboration between your CDI teams, utilization review, and the business office staff is essential to understand the current state of clinical validity denials at your facility, Reck said.
Reck says that revenue cycle leaders can’t assume that appealing a denial or MS-DRG downgrade will result in the payer responding back to you.
“In working through an internal, home-grown tracking tool for clinical validity denials, we identified a black hole with cases in which we never heard back from the payer. In following up, we often heard, ‘We didn’t get the appeal, and now you are past your timeframe to appeal,’” Reck said.
“We knew this was incorrect because we document fax confirmations on all our appeals. The follow up work for these denials needs to be discussed in your facility to determine who is best to perform a follow-up or these cases will often go through as denied, and the payer will recoup the difference of the MS-DRG on another remit,” Reck warned.
Tracking the volume of these denials is essential to understanding trends specific to certain diagnoses, MS-DRGs, and payers, Reck told us. Tracking these types of denials supports the program of work by showing that without dedicated staff managing appeals, there can be a significant loss in revenue for a health system.
The district court recently remanded remedy decisions to HHS for its underpayments related to the 340B drug pricing program.
After experiencing several key wins throughout their long legal battle with HHS, the American Hospital Association (AHA) and other industry plaintiffs were disappointed by the January ruling where a district court judged remanded HHS the question of how to repay 340B hospitals.
According to the AHA, this decision caused the repayments to be even further delayed—and a recent letter penned by the group outlines five ways the group says HHS can expediate the administrative process and avoid further legal challenges.
In the letter, the AHA calls for HHS to:
Repay each 340B hospital the full amount that was unlawfully withheld between January 2018 and September 2022
Repay each 340B hospital promptly
Not impose a prospective remedy
Pay hospitals interest on its underpayments until they are fully repaid
Not recoup funds from the hospital field to achieve budget neutrality
"As the AHA has stated before, we are willing to work with HHS to assure a fair and equitable resolution of these issues, which have already taken far too long to resolve, at great cost to the entire hospital field," the AHA said.
"Working together, HHS and the AHA can develop a fair and administrable remedy that avoids further legal or administrative delay."
This is just the latest drama surrounding 340B payment cuts. The long legal battle between HHS and hospital groups stems from the nearly 30% cut to hospital reimbursement under the 340B program in 2018.
After a 2022 court ruling, CMS restored 340B reimbursement to the pre-2018 method of average sales price +6% for fiscal year 2023. However, to maintain budget neutrality for 2023, the agency implemented a 3.09% reduction to payment rates for non-drug services.
"Henry Ford Health system and a lot of folks rely on 340B discounts and other mechanisms like disproportionate share payments. We're a big teaching institution, so a lot of these special payments that we do in order to teach the healthcare leaders of the future or make sure that we can take care of vulnerable patients are extremely important," Damschroder said.
"So that is an area that we and others are actively—in our advocacy—ensuring that these programs stay intact or evolve to a place that enhances the programs for the people that were trying to care for," said Damschroder.
Revenue cycle leaders should have their teams stay up to date on these regulations to ensure their organization understands how these changes to reimbursement will affect their organizations throughout the year.
Avera Health's billing services officer details the system's pain points and what's ahead for 2023.
Economic hardships have been increasing each year for hospitals. Even worse, 2022 was the worst year financially for hospitals and health systems since the COVID-19 pandemic began, and revenue cycle leaders are not off the hook.
Declining operating revenue for health systems, payers squeezing even harder on denials, and a fundamental shift in the workforce have been creating trying times for our revenue cycle leaders.
These hardships are pushing leaders to consider changes in 2023 and as Amanda Schutz, billing services officer at Avera Health says, remedying staffing challenges and implementing automation will be a priority for the health system this year.
Staffing has been a primary challenge for Avera Health’s revenue cycle in the last few years, Schutz says. To stay competitive, Avera has had to allow for more flexibility during working hours and grant staff the ability to work from home.
To remedy further staffing challenges, Schutz plans to advocate for the revenue cycle to make greater financial investments in automation for 2023. “That could be through AI, bot technology, or any technology that allows us to be more efficient in our day-to-day work,” she says. “With the cost of staff, we have to get more creative when it comes to automation.”
Pictured: Amanda Schutz. Photo courtesy of LinkedIn.
“I’m excited to be part of our automation/technology discussion and decisions at Avera. This is an area that we need to continue to dig into and decide what technology will allow our revenue cycle to run more efficiently,” Schutz says.
Schutz will be joining us at this month’s Revenue Cycle Exchange to talk through these pain points and more.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
Prior authorizations and price transparency will be a main focus of advocacy for 2023.
Each year the American Hospital Association (AHA) releases an advocacy agenda focusing on key areas in need of “critical support” for hospitals and health systems, and this year, quite a few key areas will be focused on your revenue cycle.
“Hospitals and health systems are dealing with unprecedented challenges as they manage the aftershocks and aftermath of COVID-19. These include historic workforce shortages, soaring costs of providing care, broken supply chains, severe underpayment by Medicare and Medicaid, and an overwhelming regulatory burden, just to name a few,” the AHA said.
To address these challenges, this year’s agenda is broken down into four main areas of action:
Ensuring access to care and providing financial relief
Strengthening the healthcare workforce
Advancing quality, equity, and transformation
Enacting regulatory and administrative relief
Most of these key areas include specific agendas related to the revenue cycle.
The group says it wants to enact technological, legislative, and regulatory solutions to reduce administrative waste by streamlining prior authorization requirements and processes for hospitals so that clinicians can spend more time on patients rather than paperwork.
It also plans to support price transparency efforts by ensuring patients have access to the information they seek when preparing for care, including cost estimates when appropriate, and creating alignment of federal price transparency requirements to avoid patient confusion and overly burdensome duplication of efforts.
When it comes to surprise billing, the AHA says it plans to ensure that regulations to implement surprise medical billing protections for patients do not inadvertently restrict patient access to care.
Social determinates of health capture also made the agenda. The AHA says it will promote approaches to account for social risk factors in quality measurement programs where appropriate to ensure equitable performance comparisons and payment adjustments, and promote alignment and standardization of approaches to collecting, analyzing, and exchanging demographic and health-related social need data across federal agencies.
The AHA says it will work with Congress, the administration, regulatory agencies, courts, and others to positively influence the public policy environment for patients, communities, and the healthcare field.
There is much more than just revenue cycle-related challenges being addressed. The hospital association is also placing a focus on workplace violence, Medicare residency slots, the nursing shortage, and workforce diversity. Read more about those initatives here.
A new survey highlights the importance of digital options in improving the patient experience.
Does your revenue cycle have poor digital engagement options? Well, it might be costing you patients, a new survey shows.
At a time when a positive patient experience is playing a heavy role in overall reimbursement, a new report from Accenture says patients are becoming more comfortable switching providers when their current one isn’t meeting their needs.
According to the report, many patients are finding it difficult to navigate their care journey.
78% of patients that switched health systems cite ease of navigation factors as the reason for leaving. These factors include difficulties in doing business, bad experiences with front-end staff, and inadequate digital solutions, the report says.
The report, which surveyed 10,000 US consumers between October and November 2021, also highlighted the need for technology in the revenue cycle as digital engagement played a large role in provider loyalty.
According to the report, nearly 80% of “highly digital” patients are likely to stay with their providers. This is more than 20% greater than all other digital engagement categories, the report says.
Although the report doesn’t cite specific digital engagement options, digital front doors, streamlined patient portals, and digital billing options have all been linked to a more positive patient experience within the revenue cycle.
Now, The American College of Emergency Physicians, American College of Radiology, and American Society of Anesthesiologists are showing support to the TMA as the groups filed a joint amicus brief with the court.
The groups say the issues outlined in the TMA’s suit hinders physicians and facilities from engaging in fair contracting negotiations with insurers, which could threaten their ability to operate and may result in patients losing access to in-network care.
The initial administrative fee for the IDR process was set at $50 and it was announced in October 2022 it would remain at $50 for 2023, but in January, the agencies revealed a 600% hike in the fee due to increasing expenditures in the IDR process, among other reasons.
"The steep jump in fees will dramatically curtail many physicians’ ability to seek arbitration when a health plan offers insufficient payment for care," the TMA said.
The amicus brief also outlined the flawed qualifying payment amount (QPA) process.
The medical societies say the methodology for calculating the QPA artificially deflates the QPA by:
Establishing each contracted rate as a single data point
Excluding incentive-based and retrospective payments
Including rates for physicians in different specialties
Allowing third-party administrators to determine the QPA based on contracted rates recognized by all self-insured group health plans administered by the third-party administrator
"The inaccurately calculated QPA compounds the defects of the biased IDR process under the August final rule, which favors the QPA and empowers insurers to significantly reduce their in-network rates or terminate in-network agreements altogether," the groups say.
