Client News Coverage

The prior authorization process has evolved in complexity as the healthcare industry transitions from fee-for-service to value-based care. At the same time, payers are expanding the number of services subject to prior authorization to establish medical necessity and appropriateness. It’s a one-two punch that leaves providers and provider organizations struggling under the weight of a prior authorization burden that, left unaddressed, can have long-term revenue cycle impacts.

Today’s prior authorization process involves time-consuming steps, including gathering and submitting medical documents to insurance companies and waiting for approval. It also often involves dealing with denials and appeals – all while guidance around required documentation becomes stricter.

When you go to implement new technology into your organization, it’s important to look at all of the ways that it can go wrong so that way you can ensure you have safeguards and procedures in place. However, it is equally important to look at all of the ways that it can benefit your organization. After all, the ways that new technology improves the care of our patients and improves the work life of our staff is the sole reason we implement it. So while there are challenges and concerns with AI, let’s take a moment to look at its benefits and its potential.

We reached out to our talented Healthcare IT Today Community and asked them – what novel ways are you seeing AI being applied to healthcare? Where hasn’t it been applied yet that you think it should be? The following are their answers to these two questions.

The charge description master, or CDM, is vital to the revenue cycle, serving as the central comprehensive file of a hospital’s chargeable items. It includes such entries as diagnostic tests, procedures, supplies, prescription drugs, and fees for equipment and room use. According to the AACP,

“Every patient revenue dollar that flows through an organization is generated through this file. Hospitals that take great care to ensure their CDM is correct are able to optimize their revenue cycle for enhanced patient experience and improved financial sustainability.”1

The quest for a national patient identification system goes all the way back to the introduction of HIPAA in 1996. Yet decades later, the health care industry is still no closer to achieving the original goals laid out, as detailed by an op-ed that appeared in the HIPAA Journal last year.1

And while the public-private debate continues over where ownership of a patient identification standard should live, the industry at large recognizes there is much at stake when it comes to accurate patient matching and safety. The shortfalls of patient mismatching and inaccuracies are well established in the industry and can lead to information gaps in patient records, repeated testing, delayed care, and unnecessary costs. Notably, one recent study conducted by Patient ID Now revealed organizations are spending 110 hours per week resolving patient identity issues, and one-third are spending $1 million annually on patient matching.2

One in 4 adults in the U.S. has a temporary or permanent disability, including visual, auditory, cognitive and mobility impairments—a number that will climb as the population ages. Nearly half (46%) of Americans aged 75 and older report having a disabilitycompared to just 24% of those 65 to 74 and 12% of those 35 to 46.

The prevalence of disability is why the health IT developer community must prioritize electronic health record (EHR) designs that advance disability inclusion across healthcare, allowing patients, providers and other healthcare workers requiring accommodation to fully and effectively participate in both the provision and receipt of healthcare.

The HIMSS Electronic Health Records Association recently analyzed how healthcare organizations collect social determinants of health information.

While EHRA's Social Determinants of Health and Health Equity Task Force sees great value in using SDOH to help address healthcare disparities, it says a gradual transition toward more widespread adoption of standardized screeners – in sync with the health IT industry's evolution and readiness to adopt new tools – is the correct approach.

A task force of the EHR Association has made recommendations for how social determinants of health (SDOH) data should be captured in electronic health records.

The association’s Social Determinants of Health and Health Equity Task Force's recently published “Recommendations for Determinant Capture,” notes that there is currently a lack of consensus around which SDOH domains should be assessed by healthcare providers and a standardized approach to capturing the necessary information.

In fact, as inpatient organizations prepare to start reporting on patient screenings for social determinants in 2024, the EHR Association advises that CMS consider postponing this requirement. “This delay would allow for sufficient time to gather insights and learn from industry practices,” the task force said.

Time-consuming and cost-intensive processes within outdated patient access and financial clearance operations contribute to delays in the patient journey from the initial point of contact to the date of service – delays that introduce inefficiencies into the process and contribute to lost revenues. Streamlining these patient access processes is crucial to ensuring that patients are financially secure and have timely access to necessary medical services.

A synchronized financial clearance methodology centered around a well-designed and efficiently operated patient access team and modernized processes will accelerate revenue by decreasing payment delays caused by front-end errors, reducing rescheduled appointments, and improving patient satisfaction. Driving this patient access overhaul are new technologies and innovative solutions that streamline operations by engaging people, processes, and technology through collaboration and communication.

Medicare providers in hospitals and skilled nursing facilities (SNFs) are adjusting to new split/shared services documentation and billing regulations rolled out by the Centers for Medicare and Medicaid Services (CMS) as part of the 2024 Medicare Physician Fee Schedule (MPFS) final rule. The most notable change within the new regulations, which took effect on Jan. 1, 2024, is the finalization of CMS’s definition of the “substantive portion” of a split/shared evaluation and management (E/M) visit.

The ability for healthcare providers to appropriately connect with and securely share electronic health information with network stakeholders that are managing patient care is critical to support care coordination, continuity, and improved clinical decision support.

It is also crucial for supporting the patient’s ability to fully access their health record and enabling authorized parties to access any relevant and appropriate information for other purposes such as healthcare operations, benefits determination, public health and other authorized purposes.

In the months that have passed since the Office of the National Coordinator for Health Information Technology (ONC) issued the final Health Data, Technology, and Interoperability: Certification Program Updates, Algorithm Transparency, and Information Sharing (HTI-1) rule, the health IT sector has been working diligently to meet the earliest compliance timelines even as it continues an in-depth analysis of the regulatory impact on both developers and the providers who use certified technology.

There happen to be numerous overlapping federal requirements, such as the need for annual projects in order to maintain information blocking compliance as well as aggressive time frame when it comes to decision support certification, go ahead and represent big challenges for the health IT developers, according to the leaders from the HIMSS Electronic Health Record Association.

With a spate of regulations that happen to be driving the health IT product development, being in compliance with the regs that do not always work well with each other happens to be a big ask, as per Leigh Burchell, who happens to be the vice chair of the EHRA’s information blocking compliance task force as well as a member of the organization’s executive committee.

Hospital & Healthcare Management»

Several overlapping federal requirements – including the need for annual projects to maintain information blocking compliance and an aggressive time frame for decision support certification – represent big challenges for health IT developers, say leaders from the HIMSS Electronic Health Record Association.

Taking the risk to start a company is a feat few are fully equipped for. Any business owner knows that the first few years in business are anything but glamorous. Building a successful business takes time, lessons learned, and most importantly, enormous growth as a business owner. What works and what doesn’t when one starts a new business? What are the valuable lessons learned from the “University of Adversity”? As part of this interview series, I had the pleasure of interviewing Bill Wolfe.

Bill Wolfe is a senior executive with experience in both large corporations such as Cisco, Verisign, and Openwave, and startups including Hawk Systems, ISOCOR (IPO), Clickatell, and now YourHealth. He has held positions including CTO, CSO, Senior Vice President with P&L responsibility, and a variety of VP/General Management positions, with versatile experience including sales, product management, engineering, and M&A. With a passion for motivating talent through clear objectives and accountability, he has consistently delivered growth-oriented profitable operations on a global scale

Medium»

Best Practices for Transitioning to a New HIM Vendor—Why, When, and How

The HIM outsourcing market continues to thrive, with ResearchandMarkets.com projecting a compound annual growth rate (CAGR) of more than 12% for medical billing outsourcing between 2023 and 2030, during which its value will expand from $12.2 billion to $30.2 billion. Data Bridge Market Research further projects that the health care revenue cycle management outsourcing market will reach $8.56 billion by 2030, a CAGR of 15.2%.

Behind the rapid growth trajectory is a confluence of trends. A survey by Black Book Research found that 98% of hospital leaders plan to bring in more third-party vendors for cost efficiencies and to allow internal resources to be focused on priorities, including improving patient access, acquiring replacements for aging equipment, bettering profit margins, and implementing digital technologies. Further, as provider organizations look for ways to find adequate staff and reduce costs, outsourcing has emerged as a valid strategy to achieve a financially healthier organization.