The Useful 5: Regulatory Roundup for Rev Cycle Leaders

HealthLeaders' regulatory round up series highlights five essential governing updates that cover every aspect of the revenue cycle that leaders need to know. Check back in each month for more updates.

The revenue cycle is complex, detailed, and always changing, so staying on top of regulatory updates and latest best practices requires revenue cycle leaders' constant attention in this ever-changing industry.

In this revenue cycle regulatory roundup, there were an ample number of updates published by CMS and the OIG in December, including insights on telehealth use and the OIG's semiannual report to Congress.

Here are the five updates you need to know.

There was a dramatic increase in telehealth use during the first year of the pandemic.

The OIG published a report in conjunction with the Department of Defense, Office of Personnel Management, Department of Veterans’ Affairs, Department of Labor, and Department of Justice, to examine telehealth across select health care programs within those agencies and potential program integrity risks during the first year of the COVID-19 pandemic.

The report showed an unsurprisingly dramatic increase in telehealth use during the first year of the pandemic, as approximately 37 million individuals–13 times the number of individuals from the previous year–across healthcare programs in those six agencies used telehealth during the first year of the pandemic. 

The percentage of individuals using telehealth varied by program, as the VA had the most telehealth usage (87%), followed by Tricare (49%) then Medicare (43%). The Department of Justice prisoner health care services saw the lowest rate of telehealth usage (2%).

The report also looked at ways the agencies made telehealth available during the pandemic, how the coverage compared across agencies, and potential program integrity risks across programs. It identified potential risks–such as upcoding, duplicate claims, high-volume billing, unnecessary durable medical equipment, or laboratory tests associated with telehealth visits–which will likely be future areas of focus for the OIG. 

The OIG's Fall 2022 Semiannual Report to Congress was published.

Also in December, the OIG published its Fall 2022 Semiannual Report to Congress, which reviews OIG work from April 1 to September 30, 2022. The OIG detailed its monetary totals for expected recoveries and highlighted its most significant audit findings from this period.

Labs with questionably high billing for additional tests alongside COVID-19 tests warrant further scrutiny the OIG said.

The OIG also published a review of certain diagnostic testing along with COVID-19 tests. These add-on tests included individual respiratory tests (IRT), respiratory pathogen panels (RPP), genetic tests, and allergy tests. The OIG noted that while it is not unusual for labs to bill for multiple types of tests on the same claim, it is concerned about certain patterns of billing involving this type of testing.

The OIG examined all Part B claims paid for COVID-19 tests during 2020 with these four add-on tests. It found that 378 labs billed Part B for add-on tests at questionably high levels compared to the 19,199 other labs whose claims were examined.

OIG concerns included high-volumes of add-on tests on claims for COVID-19 tests, high payment amounts from including add-on tests, and labs who billed for add-on tests in combination with COVID-19 tests with little variation among patients, suggesting the add-on tests may not have been specific to an individuals’ needs. Payment amounts for claims which included these tests were significantly higher than claims with just COVID-19 tests. The OIG referred the labs in question to CMS for further review.

A proposed rule on advancing interoperability and improving prior authorization processes was published.

CMS published a proposed rule regarding improving interoperability and reducing challenges related to prior authorization. This rule replaces a proposed rule from December 2020 titled “CMS Interoperability and Prior Authorization (85 FR 82586),” and it builds on a final rule published in May 2020 titled “CMS Interoperability and Patient Access (85 FR 25510).” This proposed rule also incorporates feedback CMS received from the December 2020 proposed rule. 

The rule is geared overall toward Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid and CHIP managed care plans/entities, and Qualified Health Plan issuers on the federal exchanges, as it aims to improve electronic exchange of health care data through various APIs.

It also includes proposals to require payers and Medicare Advantage organizations to implement electronic prior authorization and send decisions within 72 hours for expedited requests and seven days for non-urgent requests. It would add a new electronic prior authorization measure for certain hospitals and CAHs participating under the Medicare Promoting Interoperability Program and in MIPS. 

The rule also includes five requests for information on the following topics:

1. Accelerating the Adoption of Standards Related to Social Risk Factor Data
2. Electronic Exchange of Behavioral Health Information
3. Improving the Electronic Exchange of Information in Medicare Fee-for-Service
4. Advancing the Trusted Exchange Framework and Common Agreement
5. Advancing Interoperability and Improving Prior Authorization Processes for Maternal Health

CMS published a press release and fact sheet on the rule on the same date. Comments are due by March 13, 2023.

National healthcare spending grew in 2021.

CMS published a press release regarding the 2021 National Health Expenditures (NHE) Report, which found that US healthcare spending increased in 2021 by 2.7% to reach a total of $4.3 trillion in total national healthcare spending.

This was a far slower increase than the 10.3% jump in 2020, and CMS attributed the slower growth to the decline in government expenditures for health care that followed strong growth in 2020 due to the COVID-19 pandemic response. The share of the GDP devoted to health decreased from 19.7% in 2020 to 18.3% in 2021, but that is still higher than the 17.6% share from 2019. Medicare spending increased by 8.4% in 2021, a significant jump from a 3.5% increase in 2020.