Peoples Health Network received an estimated $3.3 million in overpayments between 2015 and 2016 for incorrectly billing diagnosis codes from high-risk groups.
In the recent audit, the OIG focused on seven groups of high-risk diagnosis codes, aiming to determine whether selected diagnosis codes submitted by Peoples Heath Network—a Medicare Advantage organization (MAO)—for use in CMS’ risk adjustment program complied with federal requirements.
Using data mining techniques and discussions with medical professionals, the OIG identified various diagnoses that were at higher risk for being miscoded and consolidated those diagnoses into specific groups.
The OIG selected 242 unique enrollee-years with the high-risk diagnosis codes that Peoples Health Network received higher payments for through the audit period. The review was limited to the portions of the payments that were associated with these high-risk diagnosis codes, totaling $712,200.
The OIG found that 144 of the 242 enrollee-years selected did not comply with federal requirements as they were not supported in the medical record. This resulted in a net overpayment of $412,938.
Based on these findings, the OIG recommends that Peoples Health Network, refund to Medicare the $3.3 million in overpayments, identify similar instances of noncompliance, and enhance its compliance procedures. Peoples Health did not agree with any of the OIG’s recommendations.
This is just another instance where a MAO has been under scrutiny from the OIG. The OIG recently released a study covered by HealthLeaders that stated MAOs often delay or deny services for medically necessary care, even when prior authorization requests meet coverage rules.
A concern with the Medicare Advantage payment model is the potential incentive for organizations to deny services in an attempt to increase profits, the study stated. As more and more people enroll in Medicare Advantage, the issue of inappropriate prior authorization denials can have a widespread effect.
"Denied requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers," the report said. "Although some of the denials that we reviewed were ultimately reversed by the MAOs, avoidable delays and extra steps create friction in the program and may create an administrative burden for beneficiaries, providers, and MAOs."
More revenue cycle leaders are seeing that the addition of formal revenue integrity departments aid in expansion and return on investment.
Carle Health, a health system based in Urbana, Illinois, recently launched a formal revenue integrity department.
Staff had long performed revenue integrity functions, but the need for a formal department with dedicated staffing became apparent as the organization experienced rapid expansion, Alison Davis, CPC, CEMC, head of business office operations and revenue integrity at Carle Health, recently told the National Association of Healthcare Revenue Integrity (NAHRI).
According to NAHRI, the goal of revenue integrity is to prevent recurrence of issues that can cause revenue leakage and/or compliance risks through effective, efficient, replicable processes and internal controls across the continuum of patient care, supported by the appropriate documentation and the application of sound financial practices that are able to withstand audits at any point in time.
Adding a dedicated revenue integrity department makes sense for organizations looking to optimize their revenue cycles through ways other than just automation.
Traditionally, operations, compliance, and billing departments are siloed—with clear divisions between the people, processes, and platforms in the clinical, coding, and revenue cycle departments.
That setup doesn’t lend itself to easy solutions. Getting these disparate entities to work together throughout the continuum of a patient’s clinical experience is an important goal for optimizing revenue integrity, according to NAHRI.
Over the past year, Carle Health expanded from two hospitals, two physician practices, and several rural health clinics to an additional three hospitals and another physician practice.
“What’s become apparent is the complexity introduced into our structure,” Davis says.
“As we get charges into our different external systems, our lab or our radiology departments may be extending charges into Epic interface files through a separate system or process vs. charges that are coming right out of the Epic system through different modules within that platform. Making sure that they come in with the right identifiers, even the right entity, as well as professional vs. facility has definitely become something that we have to monitor and make sure that we’re on top of.”
That complexity led Carle Health to structure its revenue integrity program to house enterprise-level charge management. The revenue integrity department supports charge reconciliation across the health system and partners with clinical and operational departments to ensure the chargemaster is effectively structured to cover all coding, regulatory, and payer-specific requirements.
Revenue integrity also investigates opportunities to apply automation to support these goals, Davis says.
Currently, Carle Health’s revenue integrity department reports up through patient financial services (PFS). The long-term plan is to carve out revenue integrity to create a truly stand-alone department, Davis says.
Revenue integrity will continue to work closely with PFS, HIM, and denials management to support shared goals such as charge routing, edit management, payer billing, and automation.
Davis currently has 32 staff in her hybrid department. Seven staff members are focused on revenue integrity, overseen by a team lead and a supervisor. The team also includes two nurses who conduct revenue charge audits. As the revenue integrity department becomes more independent, Davis is hoping to round out staffing to include more coding and clinical knowledge.
Davis also plans to launch a report that will track revenue captured through all revenue integrity efforts.
Along with developing enterprise-level charge reconciliation policies, one of Davis’ primary goals for the department is launching an external system to support root cause analysis of late charges and other charge and claim edit errors and delays.
The system will allow the revenue integrity department to conduct more pre-claim submission reviews, pinpoint systemwide bottlenecks and errors, and implement root cause solutions to prevent recurrence, she says.
No single revenue integrity model suits every organization, but by viewing core revenue integrity functions through the lens of your organization’s needs, you can create a custom model for success.
To read this entire story, check out the NAHRI Journal.
The recently released 2023 Medicare physician fee schedule proposed rule featured physician payment decreases, but it also essentially gave the go-ahead for code updates.
By and large, in the 2023 physician fee schedule proposed rule, CMS is giving the go-ahead to align its billing requirements with recent evaluation and management (E/M) guideline changes put forth by the American Medical Association (AMA) that would integrate the full family of E/M services with the guidelines that currently govern office visit codes 99202-99215, according to Part B News.
That means "other" E/M services codes would adhere to the office visit guidelines that allow code level selection to be determined by medical decision-making or time, according to the agency, the history and exam elements would no longer be a factor.
The AMA guideline changes, effective January 1, 2023, will delete all observation care codes and merge them with the initial and subsequent hospital care codes, and make numerous other changes, most of which CMS is going forward with, according to the proposed rule.
One area where CMS diverges is in its approach to prolonged services. Instead of using CPT codes put forth by the AMA, CMS is launching a series of three prolonged service codes that providers can use depending on their setting, Part B News says.
Along with these, other proposals in the rule include but are not limited to:
Delaying by one year the split-shared visits policy that was finalized in CY 2022 for the definition of substantive portion as more than half the total time.
Extending the time that telehealth services are temporarily included on the telehealth services list during the PHE but are not included on a Category I, II, or III basis for 151 days following the end of the PHE
Creating a new general behavioral health integration service that is personally performed by clinical psychologists or clinical social workers to account for monthly care integration where the mental health services furnished by these provider types are the focal point of care integration.
Making an exception to direct supervision requirements under "incident to" regulations allowing behavioral health services provided under general supervision of a physician or non-physician practitioner (NPP) when the services or supplies are provided by auxiliary personnel incident to the services of a physician or NPP.
An advisory published by the U.S Surgeon General takes aim at healthcare workforce fatigue and shines light on three remedies that leaders can apply to revenue cycle staff to ward off burnout.
Surgeon General Vivek Murthy, MD, issued an advisory on building a thriving healthcare workforce that included three ways organizations can help revenue cycle staff avoid burnout, including reexamining time spent on prior authorizations.
According to the advisory, inefficient work processes, burdensome documentation requirements, and limited autonomy can result in negative patient outcomes, a loss of meaning at work, and health worker burnout.
"As we transition towards recovery, we have a moral obligation to address the long-standing crisis of burnout, exhaustion, and moral distress across the health community. We owe health workers far more than our gratitude. We owe them an urgent debt of action," Murthy says.
The advisory gives three examples that organizations can apply to revenue cycle staff to help remedy burnout.
1: Implement new strategies and approaches
Implement new strategies and approaches developed by the 25x5 Symposium to reduce administrative burdens by 75% by 2025 so that health workers can spend more time with patients.
Example opportunities include reviewing and improving staffing, scheduling, and care team delegation plans. According to the advisory, this includes adding scribes or automating data collection for any needs that are secondary to clinical care such as billing, quality reporting, and other local healthcare system or regulatory requirements.
The advisory also suggests reviewing the volume of and requirements for prior authorizations together with health workers, streamlining fax-based work such as prior authorizations to electronic and automated systems, reducing duplicative work, and ensuring usability of EHRs.
De-implementation checklists can help address common administrative burdens in the workplace.
In this instance, the advisory points to Hawaii Pacific Health’s "Getting Rid of Stupid Stuff" program that asked employees to assess their experiences with the EHR and nominate tasks to eliminate that they found either unnecessary or poorly designed. This program resulted in 1,700 nursing hours saved per month across their health system.
2: Optimize technology
The advisory recommends health systems optimize technology to increase time spent between health workers and patients.
Example opportunities include simplifying EHR-based workflows and addressing patient and health worker usability issues with virtual care. Organizations can also utilize other innovative technologies to rapidly expand needs for team collaboration and clinical decision support, the advisory says.
3: Increase staff flexibility
Increasing work schedule flexibility and autonomy is an important aspect of avoiding revenue cycle staff burnout.
An example opportunity the advisory gives includes recognizing the scheduling needs for workers who are also parents or caregivers by providing flexibility to start and end workdays. This can help reduce staff stress and demonstrates an organization’s compassion, it says.
Other examples include opportunities for health workers to schedule their preferred off days, options to use virtual care when appropriate, job-sharing/periodic coverage options by hiring internal or external temporary contract workers, and shifting tasks and decision making across a team, the advisory says.
CMS proposes adding prior authorization for more services in calendar year 2023, according to the recently released outpatient prospective payment system (OPPS) proposed rule.
CMS recently releasedthe OPPS proposed rule that would increase Medicare hospital outpatient payment rates by a net 2.7% in calendar year 2023 compared to 2022.
Also in the rule, is CMS' proposal to require prior authorization for an additional service category: facet joint injections and nerve destruction.
According to CMS this proposal 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 says.
While CMS says it will ensure that this measure will not burden patients or providers, many are not so sure, since, as the American Medical Association previously found, prior authorizations of medical treatments and services has a negative impact on patients and physicians.
The recent survey featured 40 questions that were administered online last year. More than 1,000 practicing physicians participated in the survey, with 40% working as primary care physicians and 60% working as specialists.
The survey features several key data points.
93% of physicians reported that prior authorization led to delays of necessary care (14% always, 42% often, and 38% sometimes)
82% of physicians reported that the prior authorization process leads patients to abandon treatment (3% always, 24% often, 55% sometimes)
34% of physicians reported that prior authorization has led to a serious adverse event for a patient
24% of physicians reported that prior authorization has led to a patient's hospitalization
18% of physicians reported that prior authorization has led to a life-threatening event or required intervention to prevent permanent impairment or damage
29% of physicians reported that prior authorization criteria are rarely or never evidence-based
Physicians and their staff spend an average of 13 hours per week processing prior authorizations
40% of physicians reported having staff who work exclusively on prior authorizations
88% of physicians reported that the administrative burden associated with prior authorization is high or extremely high
51% of physicians reported that prior authorization has interfered with a patient's ability to perform his or her job responsibilities
CMS will accept comments on the proposed rule through September 13.
CMS proposes increasing outpatient hospital payment rates by 2.7% and considers paying average sales price plus 6% for drugs acquired through the 340B program.
CMS recently released the outpatient prospective payment system (OPPS) proposed rule that would increase Medicare hospital outpatient payment rates by a net 2.7% in calendar year 2023 compared to 2022.
For hospitals that participate in the 340B Drug Pricing Program and that were affected by CMS' OPPS cuts in recent years, the agency announced it would restore the payment to average sales price plus 6% for calendar year 2023, given the recent Supreme Court decision.
CMS also noted that it is evaluating how to apply the Supreme Court's decision to the prior year cuts and is seeking public comment on potential remedies affecting cost years 2018-2022.
Concerns have already started pouring in from hospital groups unhappy with the inadequate payment rate amount, much like what we saw with the recent inpatient payment system proposal.
American Hospital Association (AHA) Executive Vice President Stacey Hughes said, "We are deeply concerned about CMS' proposed payment update of only 2.7%, given the extraordinary inflationary environment and continued labor and supply cost pressures hospitals and health systems face," according to the association’s statement.
In contrast, the AHA is happy with the end of the 340B payment cuts and it demands repayment.
"Having now recognized what 340B hospitals are owed under the law, we urge the Administration to promptly reimburse those hospitals that were affected by these unlawful cuts in previous years. Additionally, we continue to urge the agency to ensure the remainder of the hospital field is not penalized for their prior unlawful policy, especially as hospitals and health systems continue to deal with rising cost for supplies, equipment, drugs, and labor," Hughes said.
Among other proposals, CMS would require prior authorization for an additional service category, remove 10 services from the inpatient only list, and add one procedure to the ambulatory surgical center covered procedures list.
CMS will accept comments on the proposed rule through September 13.
A recently released fact sheet lays out ways CMS can accurately reflect the cost of providing hospital care to patients and communities.
The American Hospital Association (AHA) released a new fact sheet urging CMS to make two critical changes to the fiscal year (FY) 2023 inpatient prospective payment system rule.
The goal of the fact sheet is to arm hospitals and health system leaders with information to share with their state representatives and senators. The ultimate goal, the AHA says, is to reflect the cost of providing hospital care more accurately to patients and communities.
AHA is requesting that CMS retrospectively adjust the market basket update for FY 2022 to account for unprecedented inflation and eliminate the productivity cut for FY 2023.
"Since the market basket and associated productivity update use historical data to forecast into the future, the current rising inflation and massive growth in expenses facing hospitals and health systems were not adequately considered in the estimates," AHA said in a recent letter to members of the House and Senate.
According to the AHA, Congress should urge CMS to use its "special exceptions and adjustments" authority to make a retrospective adjustment to these market basket amounts. In addition, Congress should urge CMS to eliminate the productivity cut for FY 2023, it said.
The American Hospital Association (AHA) urged Congress to streamline Medicare Advantage plans' prior authorization requirements in lengthy letter.
The AHA submitted a letter to the House Energy and Commerce Oversight and Investigations Subcommittee calling for greater congressional oversight to protect access to care for Medicare Advantage (MA) beneficiaries.
The letter urged Congress to support legislation for the following:
Streamline MA plans' prior authorization requirements
Prohibit MA plans from using more restrictive medical necessity and coverage criteria than traditional Medicare
Establish a provider complaint process and enforce penalties for plans that fail to comply with federal rules
Clarify states' role in MA plan oversight
"Inappropriate and excessive denials for prior authorization and coverage of medically necessary services is a pervasive problem among certain plans in the MA program. This results in delays in care, wasteful and potentially dangerous utilization of fail-first imaging and therapies, and other direct patient harms," the AHA said.
"In addition, these practices add financial burden and strain on the health care system through inappropriate payment denials and increased staffing and technology costs to comply with plan requirements. They are also a major burden to the health care workforce and contribute to worker burnout."
To this point, the AHA refers to an advisory issued last month by Surgeon General Vivek Murthy, that notes that burdensome documentation requirements, including the volume of and requirements for prior authorization, are drivers of healthcare worker burnout.
In the letter, the AHA also urges Congress to require MA plans to publicly report on standard performance metrics related to coverage denials, appeals, and grievances and for CMS to conduct more audits for plans with a history of inappropriate denials.
This latest letter from the AHA comes on the heels of last month's request for CMS to take "swift action" to hold MA plans accountable for inappropriately and illegally restricting beneficiary access to medically necessary care.
Here, the AHA cited an OIG report that found that MA organizations often delay or deny services for medically necessary care, even when prior authorization requests meet coverage rules.
A concern with the MA payment model is the potential incentive for organizations to deny services in an attempt to increase profits, the study said. As more and more people enroll in MA, the issue of inappropriate prior authorization denials can have a widespread effect.
"Denied requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers," the report said. "Although some of the denials that we reviewed were ultimately reversed by the MA organizations, avoidable delays and extra steps create friction in the program and may create an administrative burden for beneficiaries, providers, and MA organizations."
Since 2010, 138 rural hospitals have closed, with 19 shutting down in 2020 alone.
To help mitigate this trend and promote healthcare equity in rural communities, CMS released a proposed rule with conditions of participation allowing a facility to be a Rural Emergency Hospital (REH).
This conversion allows a facility provision of services, such as emergency services and observation care, that do not exceed an annual per patient average of 24 hours, according to ACDIS.
The designation of REH was created in 2021 to help curb hospital closures, and CMS seeks now to further enable small facilities and critical access hospitals in rural areas to “right-size their service footprint and avoid potential closure,” the rule’s fact sheet stated.
CMS also stated they are seeking comments on specific standards for the rural facilities. Some of these include whether a REH should be required to provide outpatient surgery services if surgical labor is necessary, and whether it can allow certain providers with training or experience in emergency medicine to be on call by telephone or onsite within a certain timeframe.
“The availability of the new Rural Emergency Hospital provider type will maintain access to essential healthcare services and help to reduce disparities in rural communities,” said Chiquita Brooks-LaSure, a CMS administrator, in a statement.
The executive director of revenue cycle management at Banner Health details lessons learned from deploying revenue cycle automation.
The healthcare industry is constantly evolving in ways that revenue cycle leaders can't control. Changes in billing requirements, payment models, and patient access can cause struggles for organizations with poor processes.
Successful organizations must enhance their revenue cycles and create the bandwidth to address these challenges. This means the use of technology and AI to streamline revenue cycle processes is essential.
Jamie Davis, executive director of revenue cycle management at Banner Health, recently spoke with HealthLeaders about Banner's journey in implementing the use of AI and automating its revenue cycle management. It wasn't an easy process, but it was necessary to protect the organization against revenue leakage.
Davis has over 20 years in healthcare and is the liaison for Banner Health's revenue cycle performance and strategic alignment with its regional c-suite. She oversees the revenue cycle portfolio, including vendor management, revenue cycle roadmap, continuous improvement, and strategy.
Banner Health currently has 22 day-to-day bots helping with its revenue cycle management. These bots complete tasks like adding insurance information and updating medical records. "All the things that our human resources shouldn't waste their time doing," Davis said.
These bots manage roughly 90 million records for Banner Health, and from mid-2020 to 2021, Banner has saved about 1.73 million man-hours by deploying them, Davis explained. Banner Health also has machine learning in its refund and variance space to help with credit and debt balances.
When it comes to taking on such a large automation endeavor, partnerships are needed Davis says.
"Our automation is done completely in partnership with our IT group. They have their own robotic process automation center of excellence, but they've also started dabbling in some process mining in our health plan data. And we are working towards automating things like low balance accounts receivable management and denials," Davis says.
"The automation of the denials, low balance accounts receivable management, and the variances is really fun and innovative. That's where it's really rolling into that intelligent automation space since it's using machine learning that is predicting and reacting," Davis says.
Don’t go big at first
While Banner Health is fully rolling with a plethora of streamlined and strategic automation throughout its revenue cycle, it wasn't always smooth sailing. This, Davis says, is where you need to make sure to take your time and don't expect to go big at first.
"In full transparency, we tried to run first, and then we fell. We realized we needed to slow down a little bit, which was a great lesson learned," Davis said. "I think anyone who is trying to be innovative has those horror stories where something worked out really well in the boardroom and not so much in real life."
At the time Davis started developing its automation, Banner Health already had its IT team working with its medical records team to manage records and move them with bots. From there, it made sense to the team to expand its automation.
"The theory is, we want our technology to pay for itself. We thought a great way to do that is to add machine learning to implant charge capture and it will increase that revenue. And we were very strategic about it—so we thought," Davis said. "We deployed process engineers and documented the processes. We found all the variants and began to write Python code and machine learning. And it worked until it didn't work. What happened was that the processes that we had documented varied from facility to facility."
Banner Health has 30 hospitals, and the appropriate workflows weren't aligning.
"So, we automated a dysfunctional workflow, and it ended up being more cumbersome to utilize the machine learning. It was a good learning experience—we did the fail-fast theory."
Moving forward
After stepping back, realigning its strategic planning, and partnering with IT, Banner's deployment process started to turn around.
"We ended up creating hierarchal scoring for all of the automation that we wanted to consider. On one side, we have the benefits: for example, net revenues, compliance, or full-time employee re-allocation. We would then weigh those scores and compare them to the complexity of the build: for example, how many process variants does it have? How many systems are in there?" Davis shared.
After gathering those scores, Banner would use a classic grid to determine automation that was low-effort, low-return, and high-effort, high-return. This hierarchical approach made all the difference for them.
"Once we did that, we applied a continuous improvement team member to have oversight and to help be that subject matter expert in the revenue cycle to make sure we aren't recreating core processes. And from there, our automation just went gangbusters," Davis said.
Banner had about five bots at the time, and in almost no time they had 15 bots. Now they are at 22, Davis says.
"And we have governance over all of it as well. So, just because we can automate something, doesn't mean we should."
Managing all of this automation has become easier too, Davis said. The team now brings all of the automation to the table, just like they would do for any other project, and explain it to governance oversight so they can agree that it's strategically aligned.
It's also important to make sure the automation doesn't tax resources that are taxed elsewhere and to make sure there is monitoring in place.
"We have dashboarding that monitors what those bots are doing, when they stopped doing it, and when they start doing it the wrong way. Because, you know, just like humans, a bot needs to learn, be educated, and be monitored," Davis said.
Davis credits its first failed attempt at deploying automation to the success it has today.
"I really think this playbook that we created has been really successful because now we have our feet under us from a bot perspective, and we are running really quickly."
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