Client News Coverage

Even as the COVID-19 pandemic grabbed much of the healthcare system’s capacity and the nation’s attention over the past two years, organizations have continued to deal with a rising undercurrent of opioid abuse.

While opioids haven’t received the press during the pandemic, the toll remains high — and grew higher, during the pandemic.

Faulty and errant documentation and coding are driving outpatient reimbursement inefficiencies, costing U.S. healthcare about $54 billion annually. Unaddressed, these costs are increasing alongside outpatient revenue, growing at a year-over-year rate of 9%.

For providers, the primary catalysts for change are an evolving regulatory environment that includes the ongoing transition to value-based care and restrictions, such as Medicare’s Two-Midnight rule. For patients, escalating healthcare costs and the convenience of outpatient care are pushing people away from hospitals.

Having identified the existing prior authorization process as a burden with wide-ranging impacts across multiple healthcare domains – contributing to provider burnout and care delays that put patients at risk – the Office of the National Coordinator for Health IT (ONC) is seeking solutions that leverage its Health IT Certification Program to advance electronic prior authorization (ePA).

An analysis by RTI International on behalf of America’s Health Insurance Plans (AHIP) agrees that the ONC’s objective is worthwhile. Published in Evaluation of the Fast Prior Authorization Technology Highway Demonstration, the analysis examined prior authorization transactions before and after implementation of ePA and found the time between request and decision was 69% faster with ePA. Time spent on phone calls and faxes also decreased significantly, and transparency of prior authorization requirements was improved.

As third-party and internal payment integrity and compliance audits ramp up, healthcare organizations need to put in place proven processes that guide immediate and effective actions in the wake of problematic findings. With the clock ticking to correct any internal processes and/or billing practices that contributed to those findings, many organizations are turning to the corrective action plan (CAP) to ensure below par outcomes are swiftly addressed and mitigated.

Healthcare organizations that work from CAPs also find the chances of future billing compliance risks drastically reduced, and the ability to achieve revenue integrity significantly enhanced.

As the nation’s death toll from COVID-19 inches towards one million, the Biden administration is intensifying efforts to inform clinicians and ordinary Americans about treatments for the disease, and to make testing and treatment more widely available.

The real-world testing of certified health information technology products is finally underway. And while health IT developers have the obligation to assess how their products perform in the real world, the testing will have both direct and indirect effects on providers, patients and others.

Real-world testing (RWT) is one of the Conditions of Health IT Certificationestablished by the 21st Century Cures Act Final Rule issued in 2020 to test health IT products’ interoperability and functionality.

We live in an age where incredible amounts of data are available to us all the time. But in healthcare, the challenge can be finding the right data, at the right moment, to achieve the best outcomes for patients. EHR technology has been game changing, but it’s also led to practitioner frustration: While EHRs can present all the data available about a given patient, they’re not always good about surfacing precisely what a physician needs.

As the industry moves toward value-based care models, clinicians have an even greater need to optimize their patient care through access to high-value information. According to physicians like Bill Hayes, MD, CMO at CPSIand a member of the HIMSS Electronic Health Record Association (EHRA) Executive Council, now is the time for stakeholders to improve EHR system functionality, and for EHR designers to enable input from clinicians and thereby ensure the most clinically relevant information is available at the point of care.

We live in an age where incredible amounts of data are available to us all the time. But in healthcare, the challenge can be finding the right data, at the right moment, to achieve the best outcomes for patients. EHR technology has been game changing, but it’s also led to practitioner frustration: While EHRs can present all the data available about a given patient, they’re not always good about surfacing precisely what a physician needs.

As the industry moves toward value-based care models, clinicians have an even greater need to optimize their patient care through access to high-value information. According to physicians like Bill Hayes, MD, CMO at CPSIand a member of the HIMSS Electronic Health Record Association (EHRA) Executive Council, now is the time for stakeholders to improve EHR system functionality, and for EHR designers to enable input from clinicians and thereby ensure the most clinically relevant information is available at the point of care.

Improper documentation and coding are driving outpatient reimbursement inefficiencies that cost the US healthcare system approximately $54 billion annually. Left unaddressed, these costs will continue increasing in tandem with outpatient revenue, which is growing at a year-over-year rate of 9 percent as consumerism and federal mandates converge to divert care away from the inpatient environment.

For providers, primary catalysts for change are: 1) the evolving regulatory environment, which includes the ongoing transition to value-based care and reimbursement restrictions such as Medicare’s Two-Midnight Rule; and 2) the expansion in the types of procedures available on an outpatient basis. For patients, escalating healthcare costs at a time when their share of the financial burden is also rising, coupled with the convenience of outpatient care, are pushing them away from hospital settings.

Industry leaders want to see more flexibility and clarity from the US Food and Drug Administration (FDA) as it seeks to finalize guidance on the use real-world data (RWD) from electronic health records (EHRs) and medical claims to support regulatory decision-making.

The comments were in response to the FDA’s draft guidance “Assessing Electronic Health Records and Medical Claims Data to Support Regulatory Decision-Making for Drug and Biological Products,” which was issued in September 2021 (RELATED: FDA issues draft guidance on RWD sourced from EHRs, claims data, Regulatory Focus 29 September 2021). The comment period closed on 24 January 2022.

A recent report from the HHS Office of the Inspector General (OIG) turned heads across the healthcare industry after pointing to a notable rise in inpatient hospital stays where upcoding was believed to be the culprit. Compliance professionals who have been in the healthcare industry any length of time know what’s next: targeted billing reviews by the Centers for Medicare and Medicaid Services (CMS) around hospital stays that are vulnerable to upcoding.

More specifically, the OIG analysis from FY14-FY19 found that hospitals are “increasingly billing for inpatient stays at the highest severity level, which is the most expensive one,” and that inpatient stays accompanied by a significant medical condition—representing the highest cost stays—grew by 20%. In contrast with high severity growth, medium- and low- severity inpatient stays dropped by 22% and 12% respectively. Based on the findings, one analysis suggests that kidney and urinary tract infections, pneumonia and renal failure were conditions likely to have a classification as high severity.

A report issued in early 2021 by the US Department of Health and Human Services (HHS) Office of the Inspector General (OIG) raised a number of red flags that should be informing hospital and health system audit strategy for the foreseeable future. Covering fiscal year (FY) 2014 through FY2019, the OIG analysis points to a notable rise in costly inpatient hospital stays—many coded at the highest severity level.

The report, which cautioned its findings were based only on an analysis of claims data and not the medical record review necessary to determine appropriateness, found that the number of stays at the highest severity level increased almost 20 percent during the time frame examined and decreased for each of the other severity levels.

As we face the third year of the global pandemic, hospitals and health systems are desperate to shore up bottom lines that have been battered by ongoing financial losses projected to exceed $100 billion in 2021. The key to undoing some of the financial damage is optimizing revenue flow and reducing compliance risk, which requires an understanding of the exact driving forces behind the devastating losses.

For many healthcare organizations, the primary problem can be traced to bundling errors, COVID-19 claim denials, and a range of coding issues.

That’s according to Hayes’ inaugural auditing and revenue integrity report, Healthcare Auditing and Revenue Integrity: 2021 Benchmarking and Trends Report, which analyzed more than $100 billion worth of denials and $2.5 billion in audited claims. It found that bundling errors were the top culprit behind the 34% of inpatient hospital charge initially denied in 2021, each with an average value of $5,300. Internal auditors also identified a significant number of concerns centered around disagreements between procedure codes and diagnoses, contributing to 33% of all internal audits containing “disagree” findings.

As the Omicron variant spreads across the US and the delta variant continues to push COVID-19 cases higher, it’s a grim reminder that the COVID-19 pandemic is far from over. Although 60% of the country is vaccinated with multiple doses and many lessons were learned by the 2020 pandemic cycle, hospitals and health systems are preparing for a rough road ahead. They are bracing for higher utilization, staffing shortfalls, and an increase in demand for COVID-related services leading to an increase in the clinical and financial pressure in days and months ahead.

Since the advent of the pandemic in 2020, healthcare organizations are trying to mitigate compliance and revenue risks. We will continue to provide data-driven insights to healthcare organizations during and after the pandemic.

An exclusive Tech Tribune Q&A with Brad Bostic (co-founder, chairman, and CEO) of hc1, which was honored in our:

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