The vice president of revenue cycle at Atrium Health explains how other revenue cycle leaders can benefit from streamlining billing statements and providing patients with financial education.
Being able to articulate to patients how much they owe in a clear and concise manner is critical and has been brought to the forefront by the No Surprises Act. An opportunity to improve a disconnect in communication can start as early as patient scheduling, check in, or check out.
Chris Johnson, vice president of revenue cycle at Atrium Health, says that although burdensome to some hospitals, the move toward price transparency is only going to help improve that patient financial experience, especially when patients are educated on the information they are being presented.
"I know it's been a difficult journey for a lot of us, and the rules that require us to do some of this don't always line up with reality of either what we can do or what needs to be done. But I still believe that it should be considered a positive thing because, ultimately, it's going to give patients more information about what they will ultimately owe out of pocket and options for resolving the out-of-pocket expense," Johnson said.
The revenue cycle space is seeing a boom in automation and technology, giving patients better access to patient portals, digital front doors, and payment options.
While patients may be getting an information overload through their bills and statements, once this information is paired down and streamlined, the advancement of technology can make the patient financial experience easier and more transparent.
Johnson echoed this point by saying that "healthcare has been providing more and more information to the patients through online portals. We are moving down multiple payment paths, trying to make that a component of the patient experience as easy as it can be."
"The ultimate goal is to give the patient the information they want, when they want it, where they want it, and how they want it, including the ability to make payments and to interact with us on their financial issues in any manner that they see fit," he said.
60% of patients surveyed were more likely to select one organization over another if able to make appointments online.
The patient experience plays an important role in the revenue cycle, and a new survey published by ModMed shows that patients will seek out organizations that prioritize timeliness, friendliness of the staff, and the use of modern technology that contribute to the overall patient experience.
The survey, which asked 2,000 patients about their experience with a doctor’s office, found that 61% place importance on how easy it is to make payments when considering whether to continue seeing a doctor, the survey said.
From scheduling their own appointments to accessing medical records to making payments from their phone, patients want greater control over how they interact with an organization, they survey said.
The survey also pointed out that the use of technology at an organization also has an impact on the perception of quality of care. 47% of respondents strongly agree that staff seem more engaged with the patients when utilizing technology.
In the exam room, 46% prefer their doctor use a tablet to review patient history. With the introduction of new technology, 54% strongly agree that their doctor seems more attentive.
When it comes time to pay the bill, more than half of patients surveyed are more likely to pay a bill faster than usual if they receive a text message reminder and are more likely to pay faster if given an online option, the survey said.
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 regulatory 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 July, including OIG audits and proposed payment rules.
Here are the five updates you should review.
Transfer claims are not getting you more money from Medicare.
The OIG published areview of the financial impact of Medicare’s transfer policy and reduced outlier threshold on Medicare total payments for transfer claims as compared to what hospitals would have been paid if the beneficiary had been discharged instead of transferred.
The OIG found that the reduced outlier threshold for transfer claims did not have a significant impact on total Medicare payments.
Under the transfer policy, Medicare decreased MS-DRG rate payments by $10.8 million. However, the reduced outlier threshold led to an increase in outlier payments by $13.7 million, resulting in a net increase of $2.9 million in total Medicare payments for transfer claims compared to what hospitals would have been paid if the beneficiaries had been discharged. This total was not significant enough to indicate a need for policy changes, and the OIG therefore had no recommendations.
2023 Medicare physician fee schedule proposed rule was published this month.
CMS published the 2023 Medicare physician fee schedule (PFS) proposed rule. The rule proposes decreasing the conversion factor down from $34.61 in 2022 to $33.08 in 2023. Other proposals in the rule include but are not limited to:
Adopting coding/documentation changes for E/M visits (including hospital inpatient, observation, emergency department, and more) that align with changes made by the AMA CPT Editorial Panel for January 1, 2023. This includes eliminated use of history and exam to determine code level, revised interpretive guidelines for levels of medical decision-making, and the choice of medical decision-making or time in determining code level.
Delaying by one year the split-shared visits policy that was finalized in 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 at 42 CFR 410.26 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.
CMS is seeking comments on a variety of topics from the rule, such as how to improve global surgical package valuation and pay more accurately for global surgical packages under the PFS, the potential use of the proposed and updated Medicare Economic Index cost share weights in calibrating payment rates, changes in coding and policies regarding skin substitutes, and more.
The 2023 outpatient prospective payment system (OPPS) proposed rule was also released this month.
CMS released the 2023 OPPS Proposed Rule. While the rule proposes paying for drugs and biologicals acquired through the 340B program at average sales price (ASP) minus 22.5%, it notes that the Supreme Court’s decision in American Hospital Association v. Becerra now prevents CMS from varying payment rates for drugs and biological in the way the 340B payment currently varies.
CMS did not have sufficient time before publishing the proposed rule to account for the Supreme Court’s decision, and it noted in the fact sheet for the rule that it anticipates applying a rate of ASP plus 6% for 340B drugs in the final rule. The rule proposes updates to both OPPS and ambulatory surgical center payment rates by 2.7% for 2023. Other proposals in the rule include:
Establishing provider enrollment procedures and payment rates for rural emergency hospitals (REH)
Removing 10 services from the inpatient-only list and adding one service to the ambulatory surgical center covered procedures list
Continuing coverage for behavioral health services furnished remotely by hospital staff to beneficiaries in their homes beyond the end of the PHE as long as the beneficiary receives an in-person service once every 12 months
Adding facet joint injections and nerve destruction as an additional service that would require prior authorization
CMS is seeking comments on a variety of topics within the rule, including whether there is additional data CMS could release on mergers/acquisitions/consolidations/changes in ownership in addition to the hospital and skilled nursing facility data CMS current releases. It also seeks comments on methodologies for counting organs to calculate Medicare’s share of organ acquisition costs and comments on payment approaches to use for software services. Comments are due on September 13.
Tighten up your billing for critical care services as health system faces new heat.
The OIG published a review of whether Lahey Clinic, Inc., complied with Medicare requirements when billing for critical care services performed by its physicians.
The OIG found that Lahey did not comply with Medicare billing requirements for 56 of the 92 critical care services reviewed. It said 54 of the critical care services billed were for patients whose conditions did not indicate that critical care services were necessary or for which the physician did not directly provide services at the level of care required for critical care services.
The OIG also found two critical care services which were billed using an incorrect CPT code. The OIG estimated that as a result of these errors, Lahey received $6,015 in unallowable Medicare payments.
The OIG recommended Lahey refund the $6,015 in overpayments, and it made procedural recommendations for Lahey to strengthen its policies and procedures. Lahey concurred with the findings for 16 of the 56 services found to be in error, but it stated that the remaining 40 critical care services were justified. The OIG said that Lahey did not provide any additional medical record documentation to support its arguments for those 40 services and therefore it maintained its original findings.
CMS is considering a new payment system.
CMS published a Report to Congress regarding a potential unified prospective payment system for post-acute care (PAC). This type of payment system was included as a provision of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014.
In this report, CMS presented a prototype for what the unified PAC PPS could be and the data analysis used to design and calibrate it. Because this type of PPS is in the very early stages of development, the report does not include any legislative recommendations, as CMS will be performing additional analysis on this topic. However, the report provides an early framework of what could be coming in terms of PAC payments in future years.
Reread some of our top stories pertaining to revenue cycle staffing challenges including a story on solutions that leaders have implemented at their own organizations.
Rev Cycle Workforce Challenges Examined at HealthLeaders Exchange
Remote work poses challenges, and revenue cycle leaders shared some of the solutions they've implemented at their own organizations to improve the remote work experience for everyone involved.
Change Your Rev Cycle Management Style for Remote Staff
At a recent HealthLeaders Revenue Cycle Virtual Exchange, industry leaders gave insight on how management styles have changed since more staff is now remote.
Poor EHR Experience Linked to Higher Clinician Turnover
Based on 59,000 clinicians surveyed, the research found that providers who are very dissatisfied with their organization's EHR are nearly three times more likely to leave in the next two years compared to those who are very satisfied with the EHR.
The workgroup takes aim at the good faith estimate (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.
This letter comes on the heels of a WEDI survey saying that the absence of a standardized data exchange puts a significant burden on providers and facilities.
According to that survey, 83.1% of providers say they are somewhat or strongly in support of the government delaying the requirement for convening providers/facilities to obtain a GFE from any co-provider until there is a standardized data exchange process in place. Only 7% are somewhat or strongly opposed, while 4.4% are neutral.
"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.
"Even though the government plans to end enforcement discretion for self-pay patients at the end of this year, currently there is no standard format or established workflow to transmit data to or from the convenor."
WEDI says it has offered its assistance as HHS develops supporting regulations and builds outreach programs to educate impacted stakeholders.
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.
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