Client News Coverage

When the federal Public Health Emergency (PHE) ended on May 11, many of the waivers that kept external audits in check also vanished. As a result, healthcare organizations are bracing for an influx of demand letters, claim changes, and heightened regulatory and billing practice scrutiny by Recovery Audit Contractors (RACs), Medicare Administrative Contractors (MACs), Supplemental Medical Review Contractors (SMRCs), Unified Program Integrity Contractors (UPICs), Targeted Probe-and-Educate (TPEs), Comprehensive Error Rate Testing (CERT), and commercial payors.

The uptick in audit activity doesn’t have to leave provider organizations exposed, however. Proper planning and a well-designed external audit strategy can ensure a rapid, effective, and compliant response while mitigating future risk.

With revenue cycle (76%), clinical administration (55%), and finance (36%) among the top five areas benefiting most from automation and artificial intelligence (AI), it’s easy to see why 98% of health care leaders say their organizations have implemented or are planning to implement AI. That includes nearly 48% that have already taken the leap, according to Optum’s annual survey on AI in health care.

However, it makes no difference how large the investment or advanced the technology solution is if the patient data flowing through it lacks integrity. In other words, when it comes to AI and patient data, the adage “garbage in, garbage out” still applies. It’s also a very real problem, as evidenced by an average duplicate patient record rate that runs as high as 18% in the typical facility and patient misidentification issues that cost the health care industry more than $6 billion in denied claims.

Patrice Wolfe, MBA is CEO of AGS Health of Washington, DC.

When health systems are immersed in data related to billing, denials, internal audits, and external payer audits, it can be overwhelming to track, manage, and process what is an overwhelming amount of raw data. Creating a value-generating revenue integrity team and pairing it with technology is the answer to harnessing that data and using it to positively affect the tight margins experienced by many healthcare organizations.

While this might seem like a bold statement, the only way to productively use your data is to employ sophisticated analytics that will provide actionable insights on how to improve billing compliance and maximize revenues.

Nashville - AGS Health works with scores of hospitals providers on revenue cycle management and helping sure organizations get money more quickly, but the company is also working with organizations on health equity.

Cheryl Cruver, chief revenue officer of AGS Health, spoke about the growing interest in health equity in a conversation with Chief Healthcare Executive® at the ViVE Conference.

Revenue cycle management solutions leader AGS Health is pleased to launch operations in Manilla, Philippines. Serving as a strategic growth partner to more than 100 major healthcare providers across the U.S., the expansion will offer AGS Health and its customers increased access to global talent.

MDaudit, an award-winning provider of technologies and analytics tools that enable premier healthcare organizations to retain revenue and reduce risk, sees the retirement of its long-time president and CEO, Peter J. Butler, effective March 31, 2023. Stepping into the CEO role will be the company’s current COO, Ritesh Ramesh.

Butler will continue serving on MDaudit’s Board of Directors and as an investor, advising on future investments and growth opportunities for the company. He has been with MDaudit for 30 years, including the past 16 as president and CEO.

The Office of Inspector General (OIG) makes no secret about the investigative target it has placed on Medicare Advantage plans and the use of unsupported hierarchical condition category (HCC) assignments. Over the past 18 months, its investigations have netted clawbacks as high as $54.3 million from SCAN Health Plan.

Nor are health plans the only ones at risk when it comes to high-risk codes. While payers may be the ones writing the checks for improper reimbursements, the providers who submitted the claims are being targeted with audits that will inevitably result in repayments to the health plan.

Healthcare organizations undoubtedly felt a sense of relief as 2022 faded in the distance, taking with it a devastating financial performance that resulted in negative profit margins for more than half of U.S. hospitals – the worst year hospitals have faced since the start of the pandemic, according to Kaufman Hall. Not only were operating margins down for most of 2022, but hospitals also struggled with higher labor costs in a more competitive market plagued by chronic clinical and administrative skill shortages.

Physician practices fared no better, with 90% saying that soaring expenses outpaced revenues last year, according to a survey by the Medical Group Management Association. Staffing and labor costs were cited most often as the source of rising costs. Other common culprits were lower reimbursement rates, significant increases in lab supply and drug costs, higher utility costs, lower patient volumes, and rising malpractice premiums.

On March 13, the HIMSS EHR Association submitted its comments to the Centers for Medicare and Medicaid Services on its Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule.

Over the years, computer-assisted coding (CAC) has proven its ability to boost revenue team productivity and accelerate critical decision-making while reducing denials, missed charges, and low-risk scores. CAC also increases coder productivity and code capture, and enables flexible and scalable coding to increase accuracy, efficiency, productivity, and flexibility.

Indeed, these benefits are why we are seeing a rapid uptick in adoption of CAC on the professional side of the healthcare house. Once reserved primarily for facility-based coding, today’s CAC solutions are stepping up to fill the void created by the chronic coder shortage that is impacting both facility and professional fee coding while helping to maximize the performance of any healthcare organization’s coding operations with improved throughput and quality – increasing coder productivity by 25%-45% and decreasing Discharged Not Finally Coded (DNFC) by between one and three days.

Revenue cycle management company AGS Health opened an office in Manila, Philippines.

AGS said in a March 7 news release the expansion will support end-to-end accounts receivable services.

The HIMSS EHR Association this week sent a letter asking the Centers for Medicare and Medicaid Services to extend the comment period on its Advancing Interoperability and Improving Prior Authorization Processes proposed rule by at least 45 days.

Health tech companies are in a tizzy: After years of letting companies roll out software tools to guide patient care with little oversight, the Food and Drug Administration is taking a tougher stance.

In September, the FDA announced its intentions to regulate many of these AI-powered clinical decision support (CDS) tools as devices — which regulators say has always been their plan and within their purview. But the industry says it was blindsided by the move. In a fierce rebuttal, the Clinical Decision Support Coalition filed a petition earlier this month asking the FDA to withdraw the final CDS guidance, arguing regulators are overstepping their bounds by trying to police medical practice. They also claim the FDA’s move violates the 21st Century Cures Act, a 2016 law that says tools that “provide limited clinical decision support” don’t count as medical devices.

FutureRx (FRx) announced today the launch of its first-of-a-kind healthcare platform for health plans and pharmacy benefits managers (PBMs) that combines modular technology solutions and, if needed, seamless access to pre-vetted fully integrated service providers on a single platform. FRx is a cloud-based, modular, user-configurable technology platform that was built from the ground up to meet complex and continuously evolving compliance requirements in today’s Medicare and Medicaid environment. As such, it is 100% compliant with government-sponsored regulations out of the box.

Once on the platform, health plan and PBM users can select from a full range of technology modules – including Rx Prior Authorization, Appeals/Grievances, Part D Stars, Drug Management Programs (DMP) and more – that are preconfigured out of the box with workflow and letters, and fully integrated with SureScripts and CoverMyMeds, as well as fax, phone, email, and mail capabilities that eliminate costly and time-consuming implementations.