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 March, including public health emergency (PHE) updates and OIG audits.
The OIG says the inability to identify denied claims in Medicare Advantage hinders its fraud oversight.
On March 2, the OIG published an issue brief regarding an evaluation into Medicare Advantage data and whether the lack of an indicator to identify payment denials in the data hinders efforts to combat fraud, waste, and abuse. CMS requires Medicare fee-for-service and Medicaid records for services to include denied claim indicators.
Medicare Advantage organizations (MAO) do not require indicators to identify a denied claim in MA encounter data, but MAOs are required to submit claim adjustment reason codes when MAOs do not pay the actual amount billed by the provider. The OIG reviewed 2019 MA encounter records to determine how many contained adjustment codes and whether they identified records that may contain payment denials. The OIG also interviewed and sent out questionnaires to involved parties about how they identify payment denials, how the lack of a denied claim indicator could impact audits and oversight work, and to determine why CMS does not require MAOs to submit this indicator.
The OIG found that the adjustment codes were used on almost all encounter records, but it was not possible to definitively determine which claims were denied using these adjustment codes. Oversight entities who spoke with the OIG said the denied claim indicator would make their efforts much easier and less burdensome. The CMS MA payment group said the indicator is not necessary and raised concerns about the potential burden on MAOs of requiring a denied claim indicator on encounter records.
The OIG noted, however, that the private companies which cover most MA enrollees are also involved in Medicaid managed care plans and therefore already have the ability to use denied claim indicators since they are required for Medicaid managed care plans. The OIG therefore recommends CMS require MAOs to definitively indicate on MA encounter data records when they have denied payment for a service on a claim.
There was an April 2023 update of the hospital outpatient prospective payment system (OPPS).
On March 10, CMS published a transmittal regarding the April updates to the OPPS. Updates include 23 proprietary laboratory analyses coding changes, a slew of updates to COVID-19 vaccine codes, updated language in the manual pertaining to various modifiers, and more.
The OIG released a COVID-19 PHE flexibilities end date.
On March 10, the OIG published a post regarding the end of its COVID-19 PHE flexibilities when the PHE ends on May 11.
The OIG outlined which flexibilities it put in place, what those flexibilities allowed, and when those will end. The flexibilities include refraining from subjecting providers to administrative sanctions for reducing or waiving cost-sharing obligations for telehealth services, exercising certain enforcement discretions in order not to impose administrative sanctions for certain remuneration related to COVID-19 that was covered under blanket waivers, and more.
Medicare improperly paid physicians for spinal facet-joint interventions, the OIG says.
The OIG published a review of whether Medicare paid physicians for spinal facet-joint interventions in accordance with Medicare requirements.
The OIG had previously found that Medicare improperly paid for these services, and it noted that facet-joint interventions are at risk for overutilization. This audit was conducted as a follow-up to previous audits, and it examined interventions from August 1 through October 31, 2021.
The OIG found that Medicare did not pay physicians for selected facet-joint intervention sessions in accordance with Medicare requirements, as 66 of the 120 sampled sessions did not comply with at least one–if not more–of the requirements.
Of the 120 sampled sessions, the OIG also found that 43 had claim lines that were billed for at least one therapeutic facet-joint injection, and 33 of those sessions should have been billed for diagnostic instead of therapeutic injections. This did not result in improper payments because the payments for therapeutic injections are the same as the payment for diagnostic injections. However, the 66 sampled facet-joint intervention sessions deemed to be paid in error totaled $18,084 in improper payments.
The OIG recommends CMS direct the MACs to recover the $18,084 in improper payments. The OIG also recommends CMS develop collaborative training programs to be used for all MAC jurisdictions and develop solutions to prevent the incorrect billing of diagnostic facet-joint injections as therapeutic facet-joint injections. CMS concurred with the OIG’s recommendations.
There was a Medicare Advantage compliance audit of Geisinger Health Plan, and it could cost Geisinger half a million dollars.
On March 20, the OIG published a review of whether select diagnosis codes that Geisinger Health Plan submitted to CMS for use in the risk adjustment program complied with federal requirements.
The OIG conducted the audit by sampling 270 unique enrollee-years across nine groups of high-risk diagnosis codes for which Geisinger received higher payments for 2016 and 2017. The OIG found that diagnosis codes for 224 of the 270 enrollee-years did not comply with federal requirements because there was not sufficient support for those codes in the medical records or Geisinger could not find the medical records to support the diagnosis codes. The OIG found that based on the results of the sample, Geisinger received at least $566,476 in net overpayments in 2016 and 2017.
The OIG recommended that Geisinger refund the federal government for the $566,476 in overpayments, identify and return similar overpayments, and examine its existing compliance procedures to identify areas where improvements can be made to ensure diagnosis codes at high risk for being miscoded comply with federal requirements. Geisinger disagreed with all of the findings and recommendations in the report, but the OIG stood by its findings.
The new diagnosis codes, which became billable on April 1, place a heavy focus on social determinants of health (SDOH).
For example, there is now a new SDOH code for reporting problems related to education and literacy is among the code additions.
Also added are codes to update the verbiage related to critical perpetrator of abuse external cause codes with that of current CDC core data collection elements and literature related to patient maltreatment and neglect — including elder abuse.
There is also a slate of new codes pertaining to “financial abuse” of adults and children. For example, the April update brings a code for adult financial abuse, confirmed, initial encounter and a code for child financial abuse, confirmed, initial encounter.
The ICD-10-CM Official Guidelines for Coding and Reporting have also been expanded to provide more examples in the SDOH section. These updates aren’t surprising since, with increasing attention on population health and quality initiatives, organizations have turned their focus on SDOH and how capturing those ICD-10-CM codes impacts their patient population and their success in caring for that population.
Aside from the new ICD-10-CM codes from the CDC, CMS also implemented 34 new ICD-10-PCS procedure codes as part of a quarterly update to the code set (which also became effective April 1).
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.
Staying abreast of these regulatory coding updates is important for revenue cycle leaders as coding—and its completeness and accuracy—has a profound impact on an organization's bottom line.
Not many regulations have had such a profound impact on patients and organizations like prior authorization requirements.
Prior authorizations involve complex, time-consuming processes which put a huge administrative burden on revenue cycle staff. Not only that, but the requirements for prior authorizations can vary between insurance plans, leading to confusion and additional administrative tasks which can take time away from patient care.
Staying up to date on regulatory changes is key to helping to reduce these burdens for your staff. Here are five recent stories on prior authorizations that revenue cycle leaders can’t miss.
Prior auths 'delay, deny, and disrupt': Major medical societies show support for reform
118 major 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. Read the story here.
Physicians say prior authorization hurts patient outcomes, wastes resources
The recent poll of 1,001 practicing physicians in December 2022 reveals the ramifications patients and providers have to deal with from health insurers imposing prior authorization practices to control costs.
Nearly nine in 10 respondents (89%) said that the administrative process had a negative impact on patient clinical outcomes, with only 2% answering that it has any positive impact. Read more here.
Hey senate, want to help rev cycle workforce shortages? Reduce prior auth requirements, support tech
The Senate Health, Education, Labor, and Pensions Committee recently published a request for information on the drivers of healthcare workforce shortages and potential solutions. The request garnered responses from several large medical associations with solutions aimed at prior authorization requirement reduction and more support in automation.
When it comes to prior authorizations, the MGMA said in its feedback that in order to address the multi-faceted causes of physician and staff burnout, Congress should examine legislative solutions to ease administrative burden and allow providers to focus on patient care, including prior authorization reform. Read the full story here.
Feds move to rein in prior authorization, a system that harms, frustrates patients
Originally focused on the costliest types of care, such as cancer treatment, insurers now commonly require prior authorization for many mundane medical encounters, including basic imaging and prescription refills. In a 2021 survey conducted by the American Medical Association, 40% of physicians said they have staffers who work exclusively on prior authorization.
So today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need, researchers and doctors say. Read more here.
Ophthalmologists ask CMS to suspend certain prior auth policies
In recent comments to CMS, the American Academy of Ophthalmology addressed CMS’ proposed rule regarding improving the electronic exchange of healthcare data, particularly in terms of addressing Medicare Advantage prior authorization processes, an area of the rule that the group says has a profound effect on patients. Read the full story here.
Revenue cycle leaders must review, update, and optimize their EHR systems regularly to ensure their efficiency over time.
Revenue cycle leaders are on the hook for ensuring their organization can maximize reimbursement, minimize revenue leakage, and improve patient care, and one sure-fire way to make sure this happens is through an optimized electronic health record (EHR) system.
As we know, having an optimized EHR system reduces the risks of lost or incomplete documentation, billing errors, and slower reimbursement. Additionally, improving the quality and accuracy of patient medical data can enhance the quality of care and reduce medical errors.
Whether heading up an EHR implementation for the first time, in the process of switching vendors, or working to update and review your current system, by streamlining implementation, revenue cycle leaders can ensure a smoother transition to an updated system and achieve a variety of benefits for both the organization and patients.
While easy in theory, EHR deployment is not a one-time effort but a continuous process that needs to reflect changes in industry trends and care provision methods.
As Liza Dzhezhora, healthcare IT analyst at Itransition, said in our sister publication PSQH, revenue cycle leaders must review, update, and optimize their systems to ensure their efficiency over time.
Dzhezhora shared a step-by-step plan with readers that covered critical aspects of a future proof EHR implementation. Here is what she had to say:
Step 1: Project planning and preparation
To properly plan out a future EHR, revenue cycle leaders needs to take these preparatory actions:
Assess the current EHR system, collecting clinicians’ feedback and identifying their core pain points.
Evaluate users’ needs and requirements and arrange them by priority. This can help to avoid a common EHR project pitfall: wasting a lot of time on developing a function that is not currently relevant.
Ensure strong leadership from the stakeholders representing each group interested in EHR implementation, like board members, clinicians, marketers, and administrative personnel. Additionally, you should start promoting the new system’s benefits early on to mitigate staff resistance, a factor that accompanies change.
Step 2: A multidisciplinary team setup
An EHR project’s success depends on more than just qualified developers; it also requires clinicians with industry-specific knowledge of hospital tasks, operations, and workflows. Hence, the EHR implementation project needs both technical and clinical perspectives.
Revenue cycle leaders should select doctors with medium to high levels of computer competence (superusers), singling them out with the help of online tests. During the project, superusers should perform four essential tasks:
Workflow mapping. Superusers can map the selected workflows and regularly update them to make sure they fully reflect clinical processes.
Drafting the needed integrations. Through their awareness of existing digital solutions, superusers can map the necessary integrations and provide the information to the development team.
Usability testing. Superusers can identify issues that are potentially dangerous for patients, like wrong dosages or units of measurement.
Mentoring. Superusers can oversee beginners’ training, helping them master workflows and daily tasks.
Doctors’ participation in the project can improve all clinicians’ understanding of the new EHR system and its place in their practice while making the implementation smoother.
Step 3: EHR system implementation
EHR implementation is a multistep process that includes several iterations of testing and debugging, followed by rollout. But before the rollout occurs, the IT team needs to choose a suitable approach: a big-bang deployment or a phased deployment.
A big-bang deployment involves immediate go-live across the healthcare facility. This tactic is fast and efficient, allowing clinicians to begin using the new system at once. However, it is only optimal for superusers and could overwhelm clinicians with below-average computer skills. A phased deployment rolls out EHR system features incrementally. For example, providers can launch their EHR in one department and then gradually deploy it across the facility. This allows users to get acquainted with the EHR at their own pace.
Step 4: Plans for the future
EHR implementation doesn’t end with go-live. The team will also need to perform regular system optimization. This usually involves three steps:
Updating the EHR feature set and workflows
Adding new integrations
Removing underused features
Leaders should plan to start on first optimizations three months after EHR rollout.
EHR implementation challenges to expect
Unfortunately, even a well-planned EHR implementation can be riddled with issues, including initial workflow disruptions and burnout among clinicians.
Fortunately, these issues are manageable. To overcome them swiftly, leaders need to:
Set up a support sub-team comprising superusers and tech experts from the IT vendor’s side to be available for support 24/7. This can lower doctors’ stress levels, as they will know they can get help at all times. For example, Valley Children’s in California deployed a new EHR during the pandemic. To prevent coronavirus exposure for the team, they set up a virtual help line for EHR implementation, where pediatricians could call and get help with EHR-related issues.
Initially, assign patients to clinicians with regard to their computer skill levels (i.e., give lesser workloads to clinicians with lower skill levels) to reduce clinicians’ stress and minimize burnout risk.
Inform clinicians about the ongoing hurdles and their resolution during the first month.
Ensure a user-friendly training model. A complicated or confusing EHR training program will increase physicians’ stress, so it makes sense to have a program that is intuitive and engaging, and to interview clinicians and nurses on their training preferences. For instance, Southern Ohio Medical Center in Portsmouth set up at-home training through their vendor to help staff train efficiently while following social distancing requirements. Thanks to the vendor’s efforts, the Center was able to provide in-person support and monitor the progress of their clinicians’ home training.
The AAO addresses prior authorization processes that the group says delay care.
In recent comments to CMS, the American Academy of Ophthalmology (AAO) addressed CMS’ proposed rule regarding improving the electronic exchange of healthcare data, particularly in terms of addressing Medicare Advantage prior authorization processes, an area of the rule that the group says has a profound effect on patients.
According to the March 13 letter that the organization shared with HealthLeaders, the AAO says it has been forcefully advocating for ophthalmologists and their patients who have been subjected to sweeping prior authorization policies delaying cataract surgeries, particularly imposed by Medicare Advantage plans.
In the letter, the AAO called for four actions from CMS:
Ensuring accountability through enforcement of decision deadlines and public reporting of denial metrics.
Avoiding potential administrative burden for provider practices by removing the unnecessary Merit-Based Incentive Payment System Promoting Interoperability measure proposal.
Adding protections for small and rural practices.
Expanding application of the rule’s provision to address other key areas of concern, such as health equity, step therapy, and Digital Imaging and Communications in Medicine standards.
Additionally, the AAO expressed concern that CMS is soliciting comments on the “approach to prior authorization within the Rule that could be applicable under Medicare fee-for-service.”
In a comment sent to HealthLeaders, the AAO noted that while the group supports CMS’ actions trying to simplify prior authorization processes, the AAO is concerned by the solicitation for comments on if and how the approach to prior authorization could be applicable under the Medicare fee-for-service payment model.
“We ardently oppose prior authorization under Medicare fee-for-service and urge CMS to suspend any existing prior authorization policies on services not mandated by legislation. We believe that prior authorization expansion in fee-for-service has the potential to harm Medicare patients’ access to necessary care and should not move forward without a specific legislative mandate,” the AAO said.
In an industry inundated with technology, how can it be used to counter patient burnout in the revenue cycle and beyond?
When revenue cycle leaders look to ease financial burdens for their organization, there is one area that can’t be overlooked: the patients.
From the patient financial experience to the clinical experience, keeping patients happy and avoiding burnout is necessary for a thriving organization. Not only can burnout negatively impact patient experience and the quality of care they receive, patient burnout can also lead to decreased patient volume and revenue for healthcare organizations.
When it comes to technology, what can be done to remedy the patient experience and avoid burnout and lost revenue?
Sidd Shah, vice president for product and business growth at Healow Health and former program lead for the New York City Health Department’s Primary Care Information Project, has seen the burnout problem up close, and recently shared his thoughts with our sister publication Part B News on how to counter patient burnout through tech and more.
Patient burnout, Shah said, isn’t just caused by the patient’s experiences at the organization; it could grow from related extrinsic anxieties, such as economic factors that the patient may relate to their ability to access care. “Or it could be about just finding the right physician opinion,” Shah said, “or taking too long to find an appointment, or the provider not being empathetic about the patient not being able to pay their medical bills.”
Expectedly, Shah suggests a role for technical solutions—for example, a “direct booking” solution for scheduling. This would prevent the confusion of competing appointment streams, he said, where “you as a consumer go to something-dot-com or to your app, and when you book you're not looking at the same schedule as the provider, and some other patient might be on the phone or on another site booking an appointment.”
Shah is also a fan of patient self-check-in: “It instills a sense of control and removes [the] paper process of filling [out] forms,” he says. It also “gives providers more time to spend with patients vs. on systems and data entry.”
Timely messaging to the patients on the day of or day prior to a pre-scheduled appointment is another way to enhance the patient experience, Shah said. “Televisits between in-person visits if schedules are heavily booked [so] patients are not waiting too long to be seen” is also a way to use tech to ease stress that can lead to patient burnout, Shah said.
The American Medical Association (AMA) recently detailed coding changes for evaluation and management reporting.
There are yet-to-be-released evaluation and management (E/M) changes on the way in 2024 and 2025, according to the CPT Editorial Summary of Panel Actions, which the AMA also published earlier this month.
But for now, there are many recent changes to this code set that your outpatient coding teams should be aware of.
As revenue cycle leaders know, coding challenges can easily lead to delays in reimbursement. When the coding process is hindered, the revenue cycle can be slowed by a backlog of charts, errors in claims, or working denials, which is why staying up to date on even the most minute changes is essential.
When it comes to recent updates, there are two small but important changes (in bold below) in the 2023 CPT Manual section “Amount and/or Complexity of Data to be Reviewed and Analyzed:”
Independent interpretation: The interpretation of a test for which there is a CPT code, and an interpretation or report is customary. This does not apply when the physician or other qualified healthcare professional who reports the E/M service is reporting or has previously reported the test. A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test. A test that is ordered and independently interpreted may count both as a test ordered and interpreted.
Appropriate source: For the purpose of the discussion of management data element (see Table 1, Levels of MDM), an appropriate source includes professionals who are not healthcare professionals but may be involved in the management of the patient (e.g., lawyer, parole officer, case manager, teacher). It does not include discussion with family or informal caregivers. For the purpose of documents reviewed, documents from an appropriate source may be counted.
“The most recent CPT errata’s clarification regarding the counting of data elements is a bit surprising,” Shannon McCall, director of HIM and coding at HCPro, told Part B News.
According to Part B News, allowing the order of a unique test and the independent interpretation of that same test to be counted separately could make it easier to classify data complexity as moderate for many encounters in the inpatient, observation, and emergency department (ED) settings.
“In EDs, especially after hours, it is not uncommon for multiple tests (imaging, labs, etc.) to be ordered and those orders may very well include ones that are eligible for independent interpretation,” McCall said.
Coders should remember that “To classify overall MDM, another of the two elements (number and complexity of problems addressed or risk of morbidity) must also be met,” McCall adds, “It would seem quite easy for EDs, since prescription drug management is likely a component of the services provided for many patients.”
This could increase reporting of ED codes 99284 (ED visit for the E/M of a patient, which requires a medically appropriate history and/or examination and moderate level of MDM) and 99285 (ED visit for the E/M of a patient, which requires a medically appropriate history and/or examination and high level of MDM), McCall said in the interview.
Compliance was based on the inclusion of machine-readable files for all items and services, as well as price display of the 300 most common shoppable services. The newest findings reveal a modest increase in compliance percentage since the previous report in August 2022, with 24.5% of hospitals (489) now compliant, compared to 16% last year.
One system that took one of the top spots in compliance was Lifepoint Health. According to the report, 73% of hospitals owned by Lifepoint Health were found to be in compliance with the price transparency law.
So how is the system working to perfect its price transparency adherence? HealthLeaders met up with Tina Barsallo, vice president of revenue cycle operations at Lifepoint Health, to chat about the health systems’ strategies.
HealthLeaders: Congratulations on achieving high marks in adherence! What was the process like for Lifepoint in adhering to price transparency requirements?
Tina Barsallo: We created an internal pricing transparency team in the year prior to the regulation’s effective date. Team members included revenue cycle operations, revenue cycle analytics, compliance, managed care, legal, and project management. Other team members were brought in as needed, such as our facility revenue cycle management leaders and CFOs.
The pricing transparency team evaluated the requirements thoroughly and outlined the proper path for Lifepoint, and then executed on each aspect to ensure the requirements were met. The team continues to meet regularly to confirm there have been no changes to the requirements, and the revenue cycle team handles on-going monitoring of the websites and links, as well as the annual refresh.
HealthLeaders: Even before the creation of your internal pricing transparency team, did you have any pre-existing processes in place, or did you have to create all new processes from scratch?
Barsallo: Prior to the rule, Lifepoint provided estimates to patients as a standard practice. Our internal tool was used as a model to develop the patient-friendly tool published on our websites for the shoppable services. The machine-readable file was newly developed from scratch, and we have worked to automate this file as much as possible.
HealthLeaders: What advice do you have for other revenue cycle leaders looking to shore up their price transparency efforts?
Barsallo: If possible, pull a team together to create joint ownership and partnership in creation of the tools and to help drive consistency and compliance. Reach out to peers to brainstorm on ways they have accomplished compliance, so you don’t need to reinvent the wheel. It is extremely helpful to collaborate with other providers and health systems. Both paths were two key activities and steps taken by Lifepoint.
Multiple medical associations respond to a request for information on workforce shortages and solutions.
The Senate Health, Education, Labor, and Pensions Committee recently published a request for information on the drivers of healthcare workforce shortages and potential solutions. The request garnered responses from several large medical associations with solutions aimed at prior authorization requirement reduction and more support in automation.
When it comes to prior authorizations, the MGMA said in its feedback that in order to address the multi-faceted causes of physician and staff burnout, Congress should examine legislative solutions to ease administrative burden and allow providers to focus on patient care, including prior authorization reform.
“MGMA urges the committee to support the next version of the Improving Seniors’ Timely Access to Care Act and work to reduce prior authorization requirements that MGMA members consistently say are the most burdensome they face every year,” the MGMA said in a statement sent to HealthLeaders.
Providers frequently experience staffing-related issues specific to the prior authorization process, and physicians are required to devote time and resources that should be spent on patient care, the group says.
Also speaking out is the American Hospital Association (AHA).
In its letter the AHA said “long-building structural changes within the healthcare workforce, combined with the profound toll of the COVID-19 pandemic, have left hospitals and health systems facing a national staffing emergency.”
One way to help? Better support the use of automation and artificial intelligence, the AHA said.
While automation is a mainstay in many sectors of the revenue cycle already, the clinical team can benefit as well.
“Hospitals and health systems are exploring the use of technology by automating certain kinds of clinical documentation, using artificial intelligence to help consolidate and trend large amounts of clinical information to provide insights for delivering care,” the AHA said in its letter.
While the AHA notes that technology cannot substitute for caregivers, it can enhance their ability to practice efficiently and reduce burden, it says. Because of this, Congress should consider providing support for the pilot testing of innovative technology solutions that support the healthcare workforce, the group says.
Organizations will soon be seeing their IDR payment determinations.
CMS just announced that certified independent dispute resolution (IDR) entities must resume making payment determinations for disputes involving items or services furnished on or after October 25, 2022.
In the same announcement, CMS said that starting last week, disputing parties will begin receiving a majority of their payment determination notices from the IDR portal.
At the time, the American College of Emergency Physicians, the American College of Radiology, and the American Society of Anesthesiologists urged CMS to quickly resume all IDR payment determinations paused by its February order.
Following a court decision that vacated nationwide the federal government’s revised IDR process, in early February CMS instructed certified IDR entities to hold all payment determinations until the departments issued further guidance.
While CMS provided some relief at the end of February when it instructed certified IDR entities to resume making determinations for payment disputes involving services provided before October 25, the associations called on the agency to resume swift determinations for disputes after that date too.
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