Client News Coverage

The relationship between payers and providers has been typically viewed as adversarial, with the prices paid to physicians and hospitals being blamed for skyrocketing healthcare costs borne by the insured, while delays and denials by insurers are blamed for falling hospital revenues.

And while the arguments on both sides appear valid, the reality is that these supposed antagonists are closer than they would initially appear when it comes to revenue and payment integrity.

Financial clearance activities are critical to constructing a strong foundation for a high-performing revenue cycle. However, a provider organization’s ability to financially secure appointments in advance of a patient’s visit is often limited by a lack of staffing, technology, and operational processes.

These limitations result in initial denials – the average rate of which increased to almost 12% in the first half of 2022 compared to just 10% in 2020 and 9% in 2016 – as well as net revenue leakage via avoidable write-offs and impacts to patient experience scores.

Healthcare IT vendors have been getting ready for two years to make patient electronic health information available for access, exchange or use on September 1, according to leaders from the Electronic Health Record Association.

They can use patient portals, other web interfaces, APIs, and an abundance of technologies and platforms to make it happen. However, while OIG published its final rule on June 27, the Office of the National Coordinator for Health IT is still working out certification rules proposed earlier this year, they told Healthcare IT News this week.

The HIMSS Electronic Health Record Association has asked the Centers for Medicare and Medicaid Services to consider time lines for IT development in its release of new payment models.

In July, the Centers for Medicare and Medicaid Services solicited a request for information for a proposed episode-based payment model. Comments were due by Thursday, August 17.

FLORIDA STARTUP MOBILEOPTIX launched what it calls its “fully equipped vision care practice on wheels” last year to provide long-term care patients with the kind of access to eyecare and eyewear they often go without due to lack of mobility. The company’s fleet of self-contained clinics caters to nursing homes — where MobileOptiX’s ECPs examine and treat both patients and care providers — and events across central Florida. INVISION spoke to MobileOptiX CEO Rob Cash about how the idea to explore this underserved niche developed, and it’s a conversation we think has implications for any eyecare practice looking to step out from behind the bricks and mortar and meet less-mobile patients where they live.

The transactional nature of revenue cycle management (RCM) makes it a prime target for automation technologies, particularly when those tools are focused on automating the manual and redundant tasks within patient access, coding, billing, and collections. In fact, automation is addressing some of RCM’s biggest pain points, increasing revenue capture and helping early adopters achieve revenue integrity.

As automation grows in popularity – nearly all healthcare organizations have an automation strategy in place today compared to less than half just four years ago – a growing number of early adopters are discovering that bespoke technologies like robotic process automation (RPA) can deliver a far more rapid return-on-investment (ROI).

When the Hospital Inpatient Prospective Payment System (IPPS) Final Rule for the 2024 fiscal year (FY) takes effect on Oct. 1, 2023, it will usher in a number of important updates and changes to reimbursement factors and programs, such as the Hospital Value-Based Purchasing (VBP) Program, Hospital Readmissions Reduction Program (HRRP), and Hospital-Acquired Condition (HAC) Reduction Program. The rule, issued in August by the Centers for Medicare & Medicaid Services (CMS), also includes updates for long-term care hospitals (LTCHs) and their payment system, as well as modifications to the LTCH Quality Reporting Program.

Notable changes for FY 2024 include the creation of 15 new Medicare Severity Diagnosis Related Groups (MS-DRGs) and deletion of 16 existing ones, as well as updates to the complications and comorbidities (CCs) and major complications and comorbidities (MCCs) lists. There are also changes to the code edits and the inclusion of new ICD-10 codes, as well as the New Technology Add-on Payment (NTAP) program.

Harris Data Integrity Solutions, the leading provider of best-in-class patient data integrity services and software, has been engaged by University Hospitals (UH) to undertake a comprehensive cleanup of UH Lake Health’s Master Patient Index (MPI) in preparation for the facility’s migration to Epic. In addition to eliminating duplicate and crossover patient records, Harris Data Integrity Solutions will support UH in clearing the hospital’s Roster Management Engine (RME) error queue.

Lake Health, which joined the Cleveland-based University Hospitals health system in April 2021, consists of UH Lake West Medical Center, UH Beachwood Medical Center, and UH TriPoint Medical Center. It is currently migrating to UH’s Epic electronic health record (EHR) system. However, prior to its patient information being integrated into the EHR, Lake Health’s MPI must be analyzed for and subsequently cleaned of any duplicate and potential crossover patient records that may exist across the UH system.

Cleveland-based University Hospitals tapped Harris Data Integrity Solutions to clean up Concord Township, Ohio-based Lake Health's patient index before transitioning to Epic.

The health system is working to eliminate crossover patient records and eliminate errors before it transitions to Epic. Lake Health joined University Hospitals in April 2021, according to an Aug. 8 Harris Data Integrity Solutions news release.

The ongoing – and worsening – labor shortage plaguing all corners of the healthcare ecosystem is hitting revenue cycle management (RCM) particularly hard, with RCM and billing departments reporting vacancy rates as high as 75%. Exacerbating an already significant challenge is the threat it poses to revenues at a time when hospital operating margins continue hovering near zero.

To keep their limited RCM teams from drowning and avoid the inevitable impact on the revenue cycle, healthcare finance executives are increasingly turning to technology to automate manual billing compliance processes and deploy advanced analytics as they recruit skilled professionals to close staffing gaps.

Overcoding is in the crosshairs as the Centers for Medicare and Medicaid Services (CMS) continues its quest to ferret out fraud and abuse and recoup improper reimbursements-a focus that returns $8 for every $1 spent on audits. There are no signs that they are letting up any time in the future, as the federal government has increased funding for audits and fraud investigations.

Overcoding-intentional or accidental-can bring significant fines in addition to repayment of the original claim. And the reputational damage of a fraud finding is hard to overcome. As such, provider organizations need to be vigilant with their compliance and education programs to avoid finding themselves on the losing end of a CMS or other third-party audit. Overpayments also have a negative impact on patient acquisition and experience, thereby deflating growth. The whole idea of declaring financial results to the public domain and restating the results repeatedly due to uncertain compliance risks is a nightmare for most of the financial leaders within health systems.

BC Advantage»

Revenue cycle management (RCM) has never been more important to the success of healthcare providers across the care spectrum, but the industry faces myriad challenges. A continuing labor shortage and lack of skilled workers threaten revenues at a time when hospital operating margins hover near zero.

While highly skilled professionals are still needed, RCM teams can work smarter and not harder by using technology to automate manual processes and deploy advanced analytics to identify the cause of denials. Further, as private insurers follow Medicare’s lead by increasing third-party audits, providers need to understand their claims and auditing process at a foundational level to support their billing practices and maximize legitimate revenue.

The payer/provider relationship is often seen as adversarial, with delays and denials by insurerstaking the blame for falling hospital revenues. But these supposed antagonists are closer than they would initially appear.

For providers, the goal of revenue integrity is to take great care of patients, maximize the reimbursement to which they’re legitimately entitled, create operational efficiencies, and maintain regulatory compliance. Contrast that with payment integrity on the payer side, the goals of which include enabling a great beneficiary experience, member retention, payment accuracy, operational efficiencies, and maintaining compliance.

The payer/provider relationship is often seen as adversarial, with delays and denials by insurerstaking the blame for falling hospital revenues. But these supposed antagonists are closer than they would initially appear.

For providers, the goal of revenue integrity is to take great care of patients, maximize the reimbursement to which they’re legitimately entitled, create operational efficiencies, and maintain regulatory compliance. Contrast that with payment integrity on the payer side, the goals of which include enabling a great beneficiary experience, member retention, payment accuracy, operational efficiencies, and maintaining compliance.

Revenue cycle management (RCM) has never been more important to the success of healthcare providers across the care spectrum, but the industry faces myriad challenges. A continuing labor shortage and lack of skilled workers threaten revenues at a time when hospital operating margins hover near zero.

While highly skilled professionals are still needed, RCM teams can work smarter and not harder by using technology to automate manual processes and deploy advanced analytics to identify the cause of denials. Further, as private insurers follow Medicare’s lead by increasing third-party audits, providers need to understand their claims and auditing process at a foundational level to support their billing practices and maximize legitimate revenue.