The Importance of Hospital Coding: Maximizing Reimbursements and Compliance

Ensuring accurate coding and compliance not only reflects your patients’ diagnoses and care but encourages your facility to exceed revenue performance goals.

Many hospitals don’t have the expertise, manpower, or time to establish coding compliance and an efficient workflow. Partnering with a revenue cycle management expert with industry experience and advanced technology can help boost your reimbursements and strengthen your hospital’s compliance.

The Role of Hospital Coding in Revenue Cycle Management

Hospital billing and coding serve as the backbone of revenue cycle management. Medical coding translates medical services, diagnoses, procedures, and equipment into a set of universal medical alphanumeric codes used for claims submission and reimbursement. It ensures hospitals and healthcare providers are reimbursed for services delivered. Coding, claims processing, and collection are all crucial revenue-generating operations for any hospital. 

Understanding the Impact of Accurate Coding on Reimbursements

Accurate coding in hospitals leads to clean claims, faster reimbursements, and a positive bottom line. Medical codes are used to support the claims sent to a patient’s insurance provider, and claims paid by patients and/or insurance companies drive the financial operations of medical organizations. 

But depending on the nature of the patient’s diagnosis and treatment, reimbursement can take weeks or months to be processed. This is why submitting the correct codes the first time around is necessary to get paid as quickly as possible. It also means that coding errors can lead to delayed payments or lost revenue.

Common Challenges in Hospital Coding and Their Effects on Reimbursements

Some of the challenges in coding for hospitals include:

• Incorrect/missing documentation – failing to provide accurate and complete documentation can result in the loss of codable components, leaving room for coding inconsistencies and decreasing your billable expense reimbursements.
• Changes in healthcare regulations and compliance standards – regulations constantly change in healthcare. Failing to stay current with these changes can lead to claim denials, payment delays, and poor cash flow.
• Coding errors – using the wrong codes puts your billing department into a repetitive cycle of claims submission, denial, correction, and payment delays, which throws a wrench into your revenue flow.
• Coding that is too general – this means taking accurate notes and abstracting all relevant information from medical reports. This process requires meticulous attention to detail. When coding is too general, hospitals miss opportunities to collect additional revenue. It also increases the likelihood of claim denials.

Strategies for Optimizing Accuracy and Efficiency

Here are three actionable tips to improve coding accuracy and efficiency:

• Leverage technology – electronic health records (EHR) bring the paper-heavy billing process into the digital age, while computer-assisted coding (CAC) helps analyze documents to identify the right medical codes for clinical documentation. These tools speed up the coding process and increase accuracy and efficiency.
• Perform regular audits – regular audits bring issues to the forefront, so you can address them promptly. Sharing learnings and feedback with coders and providers helps improve operations and coding accuracy.
• Outsource your coding – partnering with hospital billing and coding experts who work exclusively for revenue cycle management providers helps guarantee that claims are filed accurately. They can focus and pay attention to details that medical office staff may overlook in the flurry of their daily tasks and core responsibilities.

The Benefits of Proper Hospital Coding

Proper medical coding is useful for hospitals in the following ways:

• It helps ensure full reimbursement – insurance companies and other healthcare payers rely on hospitals to accurately and completely describe medical tests, procedures, and devices provided for patients. Accurate coding means getting reimbursed in a timely manner. 
• It improves patient safety – proper coding helps assess a patient’s health, identify issues in healthcare quality, and influence new and changing health policies. 
• It improves patient satisfaction – accurate hospital coding simplifies bills and helps patients understand their bills better. When billing is simplified, patients are more likely to pay quickly.

Improved Revenue Capture and Reporting

By implementing hospital coding and billing strategies, your hospital can significantly improve the efficiency and accuracy of its revenue cycle. You can minimize denials, reduce the need for time-consuming appeals, and optimize your revenue capture, leading to operational efficiency that boosts your bottom line.

Improved reporting also allows you to assess your organization’s current health by identifying errors that may occur throughout the billing process. Correcting those errors through proper reporting can reduce expenses from investigations and denied claims and, ultimately, optimize your revenue cycle from beginning to end.

Coronis Health is more than a medical billing company. We offer end-to-end revenue cycle management services that scale with your hospital. We act as your partner and help optimize your coding practices to improve the overall health of your revenue cycle. 

To learn more about hospital medical billing and how outsourcing can benefit your organization, schedule a 1:1 executive consultation with Coronis Health. 

from
https://www.coronishealth.com/blog/the-importance-of-hospital-coding-maximizing-reimbursements-and-compliance/

2024 IPPS Final Rule: Quality Programs

Over the last two weeks, we have provided the latest provisions arising from the 2024 Inpatient Prospective Payment System (IPPS) final rule released earlier this month by the Centers for Medicare and Medicaid Services (CMS). This alert will act as our final installment on the IPPS rule and will specifically focus on the CMS quality programs applicable to the inpatient hospital setting. Those provisions are summarized in a fact sheet also published by CMS, the highlights of which we have provided below.

Hospital Inpatient Quality Reporting Program

The Hospital IQR Program is a pay-for-reporting quality program that reduces payment to hospitals that fail to meet program requirements. Hospitals that fail to submit quality data or to meet all Hospital IQR Program requirements are subject to a one-fourth reduction in their Annual Payment Update under the IPPS.

The 2024 IPPS final rule (a) adopts three new measures, (b) removes three existing measures, and (c) modifies three current measures. The rule also finalizes two changes to current policies related to data submission, reporting and validation.

Specifically, CMS is adding three new electronic clinical quality measures (eCQMs) to the inventory of eCQMs from which hospitals can select to meet the eCQM reporting requirements for a given year for both the Hospital IQR and Medicare Promoting Interoperability Programs:

• Hospital Harm — Pressure Injury eCQM, with inclusion in the eCQM measure set beginning with the CY 2025 reporting period/FY 2027 payment determination.
• Hospital Harm — Acute Kidney Injury eCQM, with inclusion in the eCQM measure set beginning with the CY 2025 reporting period/FY 2027 payment determination.
• Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Hospital Level — Inpatient) eCQM, with inclusion in the eCQM measure set beginning with the CY 2025 reporting period/FY 2027 payment determination.

In addition, CMS is finalizing modifications to three current measures:

• Hybrid Hospital-Wide All-Cause Risk Standardized Mortality measure beginning with the FY 2027 payment determination. CMS is finalizing a modification to include Medicare Advantage (MA) admissions.
• Hybrid Hospital-Wide All-Cause Readmission measure beginning with the FY 2027 payment determination. CMS is finalizing a modification to include MA admissions.
• COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) measure beginning with the FY 2025 payment determination. The prior version of this measure reported on the primary vaccination series only, while the updated version of the measure reports the cumulative number of HCP who are up to date with recommended COVID-19 vaccinations to align CMS programs with the Centers for Disease Control and Prevention’s (CDC’s) definition of “up to date” vaccination, keeping the measure relevant if future vaccination guidance evolves. This measure modification is a cross-program change for the Hospital IQR Program, PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program, and the Long-Term Care Hospital Quality Reporting Program (LTCH QRP).

The final rule removes three measures:

• Hospital-level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty measure beginning with the April 1, 2025, through March 31, 2028, reporting period/FY 2030 payment determination. CMS is finalizing removal of this measure under the Hospital IQR Program in conjunction with the adoption of the recent updates to this measure in the Hospital Value-Based Purchasing Program.
• Medicare Spending Per Beneficiary (MSPB) Hospital measure beginning with the CY 2026 reporting period/FY 2028 payment determination. CMS is finalizing removal of this measure under the Hospital IQR Program in conjunction with the adoption of the recent updates to this measure in the Hospital Value-Based Purchasing Program.
• Elective Delivery Prior to 39 Completed Weeks Gestation: Percentage of Babies Electively Delivered Prior to 39 Completed Weeks Gestation measure beginning with the CY 2024 reporting period/FY 2026 payment determination. CMS is finalizing the removal of this measure because measure performance is so high and unvarying that meaningful distinctions and improvements in performance can no longer be made.

CMS is finalizing updates to the data submission and reporting requirements for the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey measure beginning with the CY 2025 reporting period/FY 2027 payment determination. These updates include three new web-first modes of survey implementation, removal of the survey’s prohibition on proxy respondents, extension of the data collection period from 42 to 49 days, limiting the number of supplemental survey items to 12, requiring the official Spanish translation for Spanish language-preferring patients, and removing two administration methods that are not used by participating hospitals. In a 2021 mode experiment, these changes, which are also being made in the Hospital VBP and PCHQR Programs, resulted in higher response rates and better representation of younger, Spanish language-preferring, racial and ethnic minority, and maternity care patients.  

Medicare Promoting Interoperability Program

CMS is finalizing the following changes to the Medicare Promoting Interoperability Program for eligible hospitals and CAHs:

• Modify requirements for the Safety Assurance Factors for EHR Resilience (SAFER) Guides measure to require eligible hospitals and CAHs to attest “yes” to having conducted an annual self-assessment of all nine SAFER Guides at any point during the calendar year in which the EHR reporting period occurs, beginning with the 2024 reporting period.
• Amend the definition of “EHR reporting period for a payment adjustment year” for participating eligible hospitals and CAHs to define the EHR reporting period in CY 2025 as a minimum of any continuous 180-day period within CY 2025.
• Amend the definition of “EHR reporting period for a payment adjustment year” such that eligible hospitals that have not successfully demonstrated meaningful EHR use in a prior year will not be required to attest to meaningful use by October 1st of the year prior to the payment adjustment year, beginning with the 2025 reporting period.
• Modify the response options related to unique patients or actions for objectives and measures for the Medicare Promoting Interoperability Program for which there is no numerator and denominator, and for which unique patients or actions are not counted. The response option for these would read “N/A (measure is Yes/No).”
• Adopt three new eCQMs eligible hospitals, and CAHs can select as one of their three self-selected eCQMs, in alignment with the Hospital IQR Program, beginning with the CY 2025 reporting period:
  • Hospital Harm — Pressure Injury eCQM
  • Hospital Harm — Acute Kidney Injury eCQM
  • Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Hospital Level — Inpatient) eCQM

Hospital Value-Based Purchasing (VBP) Program

The Hospital VBP Program is a budget-neutral program funded by reducing participating hospitals’ base operating DRG payments each fiscal year by two percent and redistributing the entire amount back to the hospitals as value-based incentive payments. In the FY 2024 IPPS final rule, CMS is finalizing the proposals to:

• Adopt the Severe Sepsis and Septic Shock: Management Bundle measure in the Safety Domain beginning with the FY 2026 program year.
• Adopt a health equity scoring change for rewarding excellent care in underserved populations such that a health equity adjustment would be added to hospitals’ Total Performance Scores (TPS) based on both a hospital’s performance on existing Hospital VBP Program measures and the proportion of individuals with dual eligibility status that a hospital treats. As a result, CMS is also finalizing the proposal to modify the TPS maximum to 110, such that the numeric score range would be 0 to 110.
• Adopt substantive measure modifications to the MSPB Hospital measure, allowing readmissions to trigger new episodes, beginning with the FY 2028 program year.
• Adopt substantive measure modifications to the Hospital-level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty, adding additional mechanical complication ICD-10 codes to the measure, beginning with the FY 2030 program year.
• Adopt changes to the data submission and reporting requirements of the HCAHPS survey measure beginning with the FY 2027 program year.
• Codify the measure removal factors, the health equity scoring change and modification of the TPS numeric score range, and the minimum number of cases.

The full provisions of the final rule can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection/2023-16252/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the.

To read an earlier alert regarding the 2024 IPPS Final Rule, click here.

With best wishes,

Chris Martin
Senior Vice President—BPO

from
https://www.coronishealth.com/blog/2024-ipps-final-rule-quality-programs/

4 Key Performance Indicators for Physician Practices

Key performance indicators (KPIs) offer physician practices a calibrated lens to gauge progression, pinpoint expansion opportunities, and illuminate areas primed for optimization or adjustments. 

These metrics act as the compass within the intricate landscape of healthcare management, navigating your course toward refined patient care, operational prowess, and continuous advancement. In this area of healthcare, KPIs a necessity, not a novelty. The challenge lies in selecting the pertinent measures that meet your practice’s distinct objectives and allow for data-driven decision-making.

Why Key Performance Indicators Matter for Physicians

Key performance indicators are measuring tools used to determine how a business performs in the long term. By measuring KPIs and benchmarking against other practices, you can better understand where you can improve and sustain excellence –because achieving profitability for your practice is more than just setting a list of goals. It requires strategic planning, tracking measurable KPIs, and taking action to adjust when needed.

Top Key Performance Indicators for Physicians

Improving on the following key performance indicators enables your practice to increase operational efficiency and, revenue, and patient satisfaction:

Marketing Metrics

Marketing strategies should be geared not just toward driving patient volume but include patient retention too. Most of your marketing metrics boil down to what you want a patient or potential patient to do (e.g., click, call, or book).

Examples of KPIs that focus on marketing and help your business grow are:

• Search engine optimization (SEO) rankings/position
• Social media metrics (number of followers and number/type of engagements for each social media platform)
• Website performance (demographics, page views, and conversion rates)
• Average star rating, patient review volume, and patient review frequency

Operational Metrics

To successfully manage and grow you practice like a well-oiled machine, look beyond patient growth and measure your operational efficiency. 

By evaluating the four operational metrics below, alongside levering technology in your practice, you can improve your workflow and efficiency by reducing no-shows, saving staff time, and providing a user-friendly platform for patients to book or reschedule appointments.

• Staff metrics (evaluate staff-to-patient and provider-to-staff ratios)
• Patient waiting time
• No-show rate
• Percentage of patients who don’t book follow-up appointments

Patient Satisfaction and Retention Metrics

Healthcare facilities and practices are in the business of customer service, and patient satisfaction is a clear indicator of the quality of your care. 

How your patients perceive the healthcare experience includes wait times, test turnaround time, and overall quality of care. By issuing surveys and questionnaires, your practice can find actionable insights about patient safety and level of care, including broader matters such as budget allocation, bonuses, and incentives for your staff. 

In addition to maintaining your current patient base, attracting new patients and ensuring they return are effective strategies for creating a thriving practice. You can track patient volume, lead conversion, and overall patient satisfaction when you measure the following:

• Total number of patients annually
• Number of new patient appointments 
• Number of return patient appointments per month
• Percentage of website visits converted to new patient appointments
• Patient satisfaction with the quality of care
• Patient satisfaction with length of stay
• Average satisfaction rate

Financial Metrics

Your total revenue measures what happens when your patients visit your practice –and whether they return or not. Consistently declining total revenue signals one or more problems to address, ranging from issues in patient billing and collections to the need for improving patient engagement and attracting new patients.

The numbers you need to measure include:

• Gross profit/net income – this reflects the proceeds that are available for reinvestment or to share with other stakeholders, and it is also a clear indicator of your practice’s financial health. In other words, this is how much money is left over after paying the costs of running your practice. Tracking your gross profits helps your practice determine whether your cash flow allows you to invest in new technologies and talents.
• Average profit per visit – this measures the average revenue from each patient visit. It tells you what income you can expect as the patient volume increases or decreases. It also measures your capacity to serve patients. 
• Cost per visit – this allows you to calculate the net revenue per patient visit by determining how overhead expenses (e.g., salaries or rent/mortgage payments) average out across the number of patients. This number provides insight into your profits and enables you to adjust your budget for other costs aside from supplies and salaries.

Hit Every KPI by Partnering with Revenue Cycle Management Thought Leaders

When you work with revenue cycle management thought leaders, you have access to cutting-edge technology and industry experts that can enhance your collections and streamline data-driven processes to put you on the path toward financial success and independence. 

At Coronis Health, we have decades of experience in billing services and revenue cycle management. We understand the competitive healthcare landscape and can provide the best tools to get you to the next level. With our complimentary revenue cycle management analysis, you gain the business intelligence needed to ensure you beat every benchmark and achieve financial prosperity.

To learn more, schedule a complimentary financial health checkup with Coronis Health today.

from
https://www.coronishealth.com/blog/4-key-performance-indicators-for-physician-practices/

Anesthesia Revenue Opportunities

Summary

It takes a certain level of financial resources and other inducements to attract and retain quality anesthesia providers. Because of these pressures on a practice, many have looked for ways to enhance their groups’ revenue streams. Today’s article explores these other revenue opportunities. 

By far, the greatest challenge facing most anesthesia practices today is the ability to generate enough revenue to recruit and retain a sufficient staff of qualified providers to meet the clinical and coverage requirements of the facilities they serve. It is the economic reality of today’s market that has made it necessary for most practices to request significant financial support from hospital administrations; fee for service collections simply do not generate enough revenue to cover the growing cost of anesthesiologists and CRNAs.

As a result of such financial challenges, many anesthesia practices have been exploring potential sources of additional revenue. As the nation’s largest provider of billing and management services to anesthesia practices, our staff has been monitoring the various initiatives and evaluating their success. Unfortunately, given the nature of the specialty, viable options are quite limited.

Bring on the Blocks

One of the most successful enhancements to the traditional scope of services has been the use of nerve blocks for acute, post-operative pain management. Virtually all insurance plans recognize the value of interscalene, femoral, sciatic and TAP blocks. Up until last year, they even made separate payment for the use of ultrasonic guidance (USG) in connection with these blocks (although, as of January 1, 2023, payment for USG is now bundled into the payment for the most common blocks).

For most practices, the employment of pain blocks has resulted in additional revenue for a variety of orthopedic cases. Many even perform TAP blocks for certain abdominal procedures. As is so often the case, though, now that the use of nerve blocks has become the norm, one can only wonder how long it will be before this revenue source is cut off.

Places of Service

A significant percentage of practices have tried to expand their scope of coverage to a variety of additional venues, including other hospitals, surgery centers and doctors’ offices. Such expansion can require a significant modification of the basic practice model. Meeting staffing requirements of the coverage and call requirements of a hospital can be challenging in itself, but having to schedule and coordinate staff among a variety of outlying venues inevitably involves the creation of a team of schedulers and potentially new software applications.

The ultimate challenge is always the evaluation of the profitability of each of these new venues. What might first seem like a logical way to deploy manpower more effectively can often become a financial loss leader. Practices that expand successfully are constantly monitoring the profitability of each venue so they can pull out of those that do not enhance the overall financial picture of the practice.

Chronic Pain Component

A team of chronic pain management specialists has become an integral part of many practices, but the jury is still out on its true value to an anesthesia practice. The management requirements of chronic pain are completely different from those of an anesthesia practice.

What makes some chronic pain practices so successful is their entrepreneurial spirit that may not be consistent with the philosophy and objectives of an anesthesia practice that is essentially captive to the contractual requirements of a hospital contract. Many a group of chronic pain specialists has broken off from the original anesthesia practice once they realized their true business potential. It should also be noted that, from a billing perspective, a chronic pain practice poses numerous unique challenges.

Exploring Ketamine Clinics

A small number of practices are attempting to explore the potential of the anesthetic agent Ketamine as a treatment option for chronic depression. This is another example of a very creative alternative.

While innovation is often the key to success in business and is often at the core of key developments in medicine it is the rare inventor who actually changes the world. It turns out that what today’s anesthesia practices really need to focus on is not finding new sources of revenue but ways to use the existing revenue more effectively. Appropriate staffing and cost management are the real keys to success in the current environment.  

If you have any questions on this topic, please reach out to your account executive.

With best wishes, 

Rita Astani
President—Anesthesia

from
https://www.coronishealth.com/blog/anesthesia-revenue-opportunities/

2024 IPPS Final Rule: Special Rules for Special Hospitals

There is a scene in the movie Tora, Tora, Tora where a group of sailors on a Japanese aircraft carrier excitedly gather around one of their celebrated pilots. When asked by one of the flight crew, “how did you rate another promotion,” the cocky pilot wryly remarked, “special people deserve special treatment,” which brought roars of laughter from his admirers.

Sometimes, special people, special situations and special institutions do require special consideration. The normal rules don’t always apply. This is the case for specially designated hospitals in the United States. Due to their unique status, special rules apply to them that don’t apply to the standard acute care hospitals. It is the purpose of this alert to address those provisions found in the recently released 2024 Inpatient Prospective Payment System (IPPS) final rule that are particularly applicable to hospitals of special designation. Below, are a few highlights arising from the rule, which originate, in part, from a fact sheet on the final rule released by CMS.

Low-Wage Index Hospitals

The Centers for Medicare and Medicaid Services (CMS) will continue its temporary policies that were finalized in the FY 2020 IPPS final rule to address wage index disparities affecting low-wage index hospitals, which includes many rural hospitals. The rule explains that CMS only has one year of relevant data (from FY 2020) that could be used to evaluate any potential impacts of this policy. Since CMS does not have sufficient data from the time period this policy has been in effect, it was determined to continue the policy while the agency obtains and reviews additional data.

Rural Emergency Hospitals

As you will recall, rural emergency hospitals (REHs) exist as a new CMS hospital classification. The REH designation was established by the Consolidated Appropriations Act (CAA) of 2021 to address the growing concern over closures of rural hospitals. The 2024 final rule includes changes to graduate medical education (GME) payments for training relative to REHs. These changes help support graduate medical training in rural areas by allowing these rural hospitals to serve as training sites for Medicare GME payment purposes after they become REHs.

Rural Wage Index Calculation

CMS has taken into consideration recent public comments that have urged it to change its wage index policies involving the treatment of hospitals that have reclassified from urban to rural under section 1886(d)(8)(E) of the Social Security Act (implemented in the regulations at §412.103). The rule finalizes the proposal to interpret section 1886(d)(8)(E) of the Social Security Act as treating rural reclassified hospitals the same as geographically rural hospitals for purposes of calculating the wage index. Specifically, CMS will include hospitals with §412.103 reclassification along with geographically rural hospitals in rural wage index calculations beginning with FY 2024. Under Section 4410(a) of the Balanced Budget Act of 1997 (Pub. L. 105–33), the area wage index applicable for any hospital that is located in an urban area of a state may not be less than the area wage index applicable to hospitals located in rural areas in that state. This provision is referred to as the rural floor. CMS will include the data of all §412.103 reclassified hospitals in the calculation of the wage index for the rural area of the state and the calculation of the rural floor for urban hospitals in the state.

Disproportionate Share Hospitals

As you’ll recall from last week’s alert the 2024 IPPS final rule contained a 3.1 percent payment increase for hospitals that meet quality and reporting requirements for FY 2024, up from the 2.8 increase that had been recommended in the proposed rule. This represents an increase in inpatient hospital payments of $2.2 billion compared to FY 2023. However, Disproportionate Share Hospital (DSH) payments will actually decrease by $957 million, according to the final rule, and CMS is projecting payments for new medical technologies will also decrease by $364 million.

The cut to DSH payments is based, in part, on an Office of the Actuary estimate that 8.5 percent of individuals will be uninsured in calendar year (CY) 2024, compared to 7.7 percent in CY 2023. According to some, this estimate is somewhat problematic. For example, in a statement released by the American Hospital Association (AHA) on August 1, the cuts were described as “inexplicable” in light of recent plunges in Medicaid enrollment.

Physician-Owned Hospitals

For a hospital to submit claims and receive Medicare payment for services referred by a physician owner or investor (or a physician whose family member is an owner or investor), the hospital must satisfy all of the requirements of either the whole hospital exception or the rural provider exception to the physician self-referral law, commonly referred to as the “Stark Law.”

To use the rural provider exception or the whole hospital exception, a hospital may not increase the aggregate number of operating rooms, procedure rooms, and beds above that for which the hospital was licensed on March 23, 2010 (or, in the case of a hospital that did not have a provider agreement in effect as of that date, but did have a provider agreement in effect on December 31, 2010, the effective date of such agreement), unless CMS has granted an exception to the prohibition on expansion. A hospital may request an exception to the prohibition on expansion of facility capacity using the process established in the 2012 Hospital Outpatient Prospective Payment System (OPPS) final rule.

The final rule accomplishes the following:

• Revises the regulations to clarify that CMS will only consider expansion exception requests from eligible hospitals, clarifying the data and information that must be included in an expansion exception request, identifying factors that CMS will consider when making a decision on an expansion exception request, and revising certain aspects of the process for requesting an expansion exception. 
  
• Reinstates, with respect to hospitals that meet the criteria for “high Medicaid facilities,” program integrity restrictions on the frequency of expansion exception requests, maximum aggregate expansion of a hospital, and location of expansion facility capacity that were removed in the CY 2021 OPPS final rule. 

Cancer Hospitals

The PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program is a quality reporting program for the eleven cancer hospitals that are statutorily exempt from the IPPS. CMS collects and publishes data from PCHs on applicable quality measures. The final rule sets forth the following:

• Beginning public display of the Surgical Treatment Complications for Localized Prostate Cancer measure beginning with data from the FY 2025 program year.
• Adoption of four new measures for the PCHQR Program:
• Facility Commitment to Health Equity beginning with the FY 2026 program year. 
• Screening for Social Drivers of Health beginning with voluntary reporting for the FY 2026 program year and mandatory reporting for the FY 2027 program year.
• Screen Positive Rate for Social Drivers of Health beginning with voluntary reporting for the FY 2026 program year and mandatory reporting for the FY 2027 program year.
• Documentation of Goals of Care Discussions Among Cancer Patients beginning with the FY 2026 program year.
• Modification of the COVID-19 Vaccination Coverage among HCP measure, in alignment with the Hospital IQR Program and LTCH QRP.
• Modification of the data submission and reporting requirements for the HCAHPS survey measure beginning with the FY 2027 program year.

Next week, we will conclude our review of the final rule by focusing on the hospital quality program.

To read more on the 2024 IPPS Final Rule, read one of our earlier alerts here.

With best wishes,

Chris Martin
Senior Vice President—BPO

from
https://www.coronishealth.com/blog/2024-ipps-final-rule-special-rules-for-special-hospitals/

No Surprises Act Update: HHS on the Losing Side Again

Summary

The back-and-forth battle between the Texas Medical Association and the federal government over the implementation of the No Surprises Act has led to yet another court decision against the government. The result is a dramatic drop in the independent dispute resolution fee amount—at least for now.

You know you’re having a bad day when you’ve just lost your third lawsuit in a row to the same group of plaintiffs. That’s especially irksome when you represent the almighty federal government and you’ve just been beaten again by a group of Texas doctors. So much for not being able to successfully fight city hall.

The context of this series of legal contests lies in the No Surprises Act (NSA), which became national law on Jan. 1, 2022. It established a federal framework for protecting in-network patients from being balance billed by out-of-network medical providers in an otherwise in-network facility. It also contained certain safeguards for self-pay and uninsured patients, such as requiring doctors and other billing practitioners to provide such patients with a good faith estimate (GFE) of the cost of the service prior to surgery.

Leadup to the Latest

One of the provisions of the NSA involves the establishment of a mediation system that the aforementioned non-participating providers can access when they believe that insurance companies have not provided them with reasonable reimbursement for services rendered. The independent dispute resolution (IDR) process allows either party to bring their complaint to a government-certified IDR mediator to make a final determination as to the appropriate payment for the medical service in question.

But, of course, going down the IDR route would not be free. In the original regulatory provision addressing the cost of the IDR process, the administrative fee for each party was set at $50. But, months later, the Centers for Medicare and Medicaid Services (CMS) increased this fee to $350, reflecting a 600 percent increase. The Texas Medical Association (TMA), which had previously brought successful suits against the U.S. Department of Health and Human Services (HHS) and CMS for what it believed to be improper NSA regulations, decided it was time to take action once more against what they felt was the latest example of government overreach.

In their January 2023 lawsuit, the TMA alleged that the change in the IDR fee “not only will make the process significantly more expensive for all IDR participants but will make it cost-prohibitive for many providers to access IDR at all.” It now appears that a federal court is singing from the same songbook.

Bringing Down the Gavel

On August 3, a judge for the U.S. District Court for the Eastern District of Texas held that HHS acted improperly when it failed to follow “notice and comment” requirements prior to its announcement of the IDR fee increases. As a result, the $350 fee was vacated by the court.

In its suit, the TMA had also disputed interim final rules that narrowed the NSA’s stipulations on “batching” claims for arbitration. The plaintiffs asserted that Congress had authorized batching to encourage efficiency and minimize costs in the IDR process and that the interim final rules had undercut this legislative intent. In his ruling, Judge Jeremy Kernolde invalidated the agency’s attempt to narrow the batching of claims.

As a result of these determinations by a federal court, the IDR process was suspended until federal agencies were able to provide additional instructions commensurate with the August 3^rd decision. The interested parties wouldn’t have to wait long to hear from the government.

The Government’s Response

In the wake of this latest federal court ruling, CMS issued a set of FAQs on August 11 as a means of providing interim guidance on the IDR process. According to the FAQs, the administrative fee for disputes that were initiated or unpaid on or after August 3 will be $50 per party until the federal departments take action on a new fee amount. For disputes initiated between January 1 and August 2 that have been paid, the fee remains $350. The judge’s order does not require a refund on administrative fees paid before Aug. 3.

Following the judge’s ruling, HHS said it temporarily suspended the initiation of new IDR actions until the federal agencies can provide additional instructions. CMS said the federal departments tasked with overseeing the IDR process “intend to reopen the portal to permit the submission of new disputes soon and will notify interested parties at that time.”

So, what are the takeaways regarding the government’s response to its latest legal defeat? First, we are faced with yet another period of “interim” rules while the government regroups to find a more permanent fix. In other words, more rulemaking is on the way. Second, even though the court vacated the $350 IDR fee, that doesn’t mean we’re back to $50 fees forever. The government said it is in the process of deciding a “new fee amount.” It will be interesting to see if the government’s response to all this will be to simply follow the notice and comment requirements in connection with a new announcement of the same $350 fee amount. After all the court’s decision to strike down the fee was based on the government’s failure to follow this technicality. So, HHS may be thinking, “all we’ve got to do is dot this “i” and cross this “t” and we’re back in business again”—that is, until the next legal challenge from Texas.

We will keep you apprised of the next developments in this ongoing story. Until then, you can access the full set of CMS’ FAQs by going to the following link: IDR Admin Fees FAQs (cms.gov). If you have any questions on this topic, please reach out to your account executive.

With best wishes, 

Rita Astani
President—Anesthesia

from
https://www.coronishealth.com/blog/no-surprises-act-update-hhs-on-the-losing-side-again/

2024 IPPS Final Rule Released: What It Means for the Inpatient Hospital Setting

Earlier this month, the Centers for Medicare and Medicaid Services (CMS) published its final rule relating to payment and other policies for the inpatient hospital setting. The 2024 Inpatient Prospective Payment System (IPPS) final rule provides regulations on a wide range of issues. The following will act to summarize some of the key provisions.

Payment Rates

The increase in operating payment rates for general acute care hospitals that are paid under the IPPS, successfully participate in the Hospital Inpatient Quality Reporting (IQR) program and are meaningful electronic health record (EHR) users is 3.1 percent. This reflects a projected FY 2024 IPPS hospital market basket update of 3.3 percent, reduced by a statutorily required 0.2 percentage point productivity adjustment.

However, hospitals may be subject to other payment adjustments under the IPPS, including:

• Payment reductions for excess readmissions under the Hospital Readmissions Reduction Program (HRRP).
• Payment reduction (one percent) for the worst-performing quartile under the Hospital Acquired Condition (HAC) Reduction Program.
• Upward and downward adjustments under the Hospital Value-Based Purchasing (VBP) Program.

The increase in operating and capital IPPS payment rates will generally increase hospital payments in FY 2024 by $2.2 billion. In addition, CMS projects Medicare disproportionate share hospital (DSH) payments and Medicare uncompensated care payments combined will decrease in FY 2024 by approximately $957 million.

Social Determinants of Health Diagnosis Codes

IPPS payment is made based on the use of hospital resources in the treatment of a patient’s severity of illness, complexity of service and/or consumption of resources. Generally, a higher severity level designation of a diagnosis code results in a higher payment to reflect the increased hospital resource use. CMS finalized a change to the severity designation of the three ICD-10-CM diagnosis codes describing homelessness (e.g., unspecified, sheltered and unsheltered) from non-complication or comorbidity (NonCC) to complication or comorbidity (CC), based on the higher average resource costs of cases with these diagnosis codes compared to similar cases without these codes. As SDOH diagnosis codes are increasingly added to claims, CMS plans to continue to analyze the effects of SDOH on severity of illness, complexity of services and consumption of resources.

New Technology Add-On Payment

To increase transparency and improve the efficiency of the NTAP program and application process, CMS is finalizing its proposal to (a) require NTAP applicants for technologies that are not already FDA market authorized to have a complete and active FDA market authorization application request at the time of NTAP application submission, and (b) to move the FDA approval deadline from July 1 to May 1, beginning with applications for FY 2025. CMS believes these policy changes will improve the completeness of submitted NTAP applications, improve CMS’s ability to provide a fuller analysis to identify eligibility concerns and allow the public the opportunity to more knowledgeably analyze applications and supporting data to provide public comment.

Hospital Readmissions Reduction Program

The Hospital Readmissions Reduction Program is a value-based purchasing program that reduces payments to hospitals with excess readmissions. It also supports CMS’ goal of improving health care for patients by linking payment to the quality of hospital care. CMS did not propose or finalize any changes to the Hospital Readmissions Reduction Program. All previously finalized policies under this program will continue to apply and refer readers to the FY 2023 IPPS/LTCH PPS final rule (87 FR 49081 through 49094) for information on these policies.

Hospital-Acquired Condition (HAC) Reduction Program

The HAC Reduction Program creates an incentive for hospitals to reduce the incidence of hospital-acquired conditions by reducing Medicare fee-for-service (FFS) payment by one percent for applicable hospitals that rank in the worst performing quartile on the measures of hospital-acquired conditions. In the FY 2024 IPPS final rule, CMS is finalizing the following proposals to:

• Establish a validation reconsideration process for hospitals that failed to meet data validation requirements, beginning with the FY 2025 program year, affecting CY 2022 discharges.
• Modify the targeting criteria for data validation to include hospitals that received an Extraordinary Circumstances Exception (ECE) during the data periods validated beginning with the FY 2027 program year, affecting CY 2024 discharges.  

Over the next two weeks, we will provide IPPS-related alerts that address (a) new rules affecting special classes of hospitals, and (b) the hospital quality program, respectively.

For more on the 2024 IPPS Rule, see one of our earlier alerts here.

With best wishes,

Chris Martin Senior Vice President—BPO

from
https://www.coronishealth.com/blog/2024-ipps-final-rule-released-what-it-means-for-the-inpatient-hospital-setting/

Understanding the Value of a Strong Collection Agency for Anesthesia Practices

Summary

There is a distinct difference in the approach and functions of a billing company and that of a collection agency. Anesthesia practices need to know the difference, in order to set appropriate expectations for each.  

Many anesthesia groups often wonder why it is difficult for billing companies to collect on patient balances. It is a reasonable query, the answer to which goes to the complexity of American healthcare economics and the distinction between the nature of a billing company and the fundamental role of a collection agency. Each type of organization is structured to provide a specific scope of services and although there might appear to be some overlap, there actually is not.

Billing companies have a very clear objective. They are designed to deliver an appropriate claim to a valid payer as expeditiously as possible and ensure that payment is timely and correct. However worthy this objective, it is complicated to achieve 100% of the time. From a client’s perspective a billing company is intended to provide as complete and as cost effective a service as possible. What clients are paying for is an extensive team of specialists who are qualified to identify all appropriate charges for billing, to submit valid claims to each patient’s insurance so long as such information is provided, to monitor payment patterns and to make a reasonable effort to collect patient balances. Large national billing companies, such as Coronis, have been investing in their software and refining their processes for years in an effort to optimize client cash flow. What clients get for this fee is consistent cash flow, a tremendous amount of timely management information and the proven advice of industry experts.

The Hard Truth

It is true that if the billing company received complete and accurate information for every case, and if patients truly appreciated the value of the services they received and had the ability to pay their share there would be no need for collection agencies to explore alternative approaches to obtaining balances due. Sadly, this is just not always the case. The fact is that in the current environment there are myriad exceptions to this ideal. Studies have shown that a significant percentage of patient demographic information obtained by hospital admitting clerks is simply inaccurate. Insurance plans capriciously question and deny valid claims. In this era of cell phones and caller ID, patients with overdue bills have become quite adept at ignoring calls from numbers they don’t recognize.  

The biggest challenge for virtually all anesthesia practices is the percentage of patients for whom there is no insurance coverage. It is always easier to collect from a patient’s insurance than from the patient. Sometimes insurance coverage can be found through diligent research, but most of the self-pay patients are truly uninsured and personally responsible for their medical bills. It has become well known that the high cost of American medicine is gradually overwhelming to many patients. In fact, it is the number one reason for bankruptcy filings in the country. The fundamental problem is that when there is no insurance coverage the anesthesia practice has little or no leverage. Their only hope is to appeal to the ethical responsibility of the patient. In many cases trying to establish contact with such patients and trying to convince them to pay is a fruitless scavenger hunt. While large national billing companies, such as Coronis, employ a variety of strategies, such as predictive dialers to contact such patients, as well as various methods in which to deliver the statement to the patient, the results are not usually impressive.

Finding What Works

While the processes of the billing company are labor extensive those of the typical collection agency are labor intensive. This is why they charge considerably more. Their fees are intended to provide a different incentive. Their fees are supposed to cover the cost of exploring a variety of alternative strategies to contact and motivate patients to pay their outstanding bills.

Successful and effective collection agencies draw on three strategies that are not typically part of the billing company scope because they would change the fee structure significantly. First, they have teams of collectors who spend their days dialing for dollars. Second, they may have access to other accounts such as the hospital, which may give them alternative approaches to patients. Third, many also use a variety of legal resources to leverage patients with liens and judgements.

Closing the Loop

What needs to be understood is that the collection agency is an option of last resort for accounts that have not responded to the normal approach and billing company processes. While billing companies should collect more than 90% of what is collectable, collection agencies rarely collect more that 30% of what is referred to them.

As is true of so many aspects of business, one cannot manage what one does not measure and monitor. Just as you monitor billing company performance, so too, it is important to monitor the collection agency performance. It is always important to ensure that the strategies and approach of the agency are consistent with the values and objectives of the anesthesia practice.  

If you have any questions on this topic, please reach out to your account executive.

With best wishes, 

Rita Astani
President—Anesthesia

from
https://www.coronishealth.com/blog/understanding-the-value-of-a-strong-collection-agency-for-anesthesia-practices/

Hospital Coding Accuracy: Best Practices for Error-Free Claims

Hospital coding accuracy is a significant component of the claims process. It’s necessary for hospitals to ensure that they receive the correct reimbursement for their services. Best practices in hospital billing and coding processes are key to guiding coders as they navigate the complexities of chart documentation. These include staying up-to-date with coding changes, automating the claims management process, eliminating workflow inefficiencies, customizing claims edits, and upgrading record-keeping technology to maintain hospital billing and coding accuracy.

The Importance of Hospital Coding Accuracy in the Claims Process

One key factor affecting revenue cycle management and quality of care in the healthcare industry is hospital coding accuracy. This relates to how well the codes assigned to diagnoses and procedures match the actual services provided and the medical conditions of the patients. Accurate coding helps to ensure that providers get paid fairly and promptly for their services and that patients are not overbilled or undercovered. Accurate coding also helps to prevent fraud, waste, and abuse in the healthcare system and to support data analysis and research for improving health outcomes and policies.

Many trends influence hospital coding accuracy in medical coding, such as:

• Coding automation tools that use artificial intelligence (AI) to assist human coders in assigning codes more efficiently and accurately.

• Shortage of skilled hospital coders due to increasing complexity and volume of coding work and the demand for higher training and certification standards.

• Transition to new ICD systems that have more codes and more specificity for diagnoses and treatments, requiring coders to update their knowledge and skills regularly.

• Revision of the Medicare Physician Fee Schedule, changing the way providers are reimbursed for evaluation and management services, which affects coding and documentation requirements.

• Implementation of coding apprenticeship programs that offer on-the-job training and mentoring for new coders helps address talent gaps and improve coding quality.

These hospital coding trends pose challenges and opportunities for hospital coders, who must adapt to changing demands and expectations of their profession. By staying updated on the latest coding standards, technologies, and best practices, hospital coders can enhance their career prospects and improve healthcare delivery and performance.

Common Errors in Hospital Coding and Their Impact on Claims

Hospital coding is prone to errors due to human error, lack of documentation, complex coding rules, and regulatory changes. These errors can significantly impact claims, resulting in denials, rejections, audits, penalties, and reduced revenue. 

• Mismatched codes – codes that do not match the documentation or level of service provided, such as using a code for a complex procedure when a simple one was performed or using a code for a diagnosis not supported by the medical record.

• Unbundling – when codes assigned are separated into individual components instead of using a single code that covers an entire service. Using separate codes for each step of a procedure instead of a code that includes all the steps results in unbundling errors.

• Upcoding – codes assigned are higher than the actual service provided or the severity of the condition, such as a code for a severe diagnosis when a mild one was present or using a code for a longer hospital stay than what was actually needed.

• Downcoding – an error in which codes assigned are lower than the actual service provided or the severity of the condition. A code used for a minor diagnosis when a serious one was present or using a code for a shorter hospital stay than what was actually needed is categorized as downcoding.

Enhancing Hospital Coding Accuracy: Key Strategies and Techniques

Hospital coding errors can occur from lack of training, outdated guidelines, or human mistakes. Essential strategies and techniques can enhance hospital medical coding accuracy and reduce the risk of denials, audits, and penalties. Strategies and techniques to enhance accuracy include:

• Providing regular education and feedback to coders on coding standards and best practices.

• Using hospital coding software and tools that can automate, validate, and audit the coding process.

• Implementing a robust quality assurance program that can monitor and measure coding performance and outcomes.

• Establishing clear and consistent communication channels between coders, clinicians, and other stakeholders involved in the documentation and coding process.

• Encouraging a culture of continuous improvement and innovation that can foster coding excellence and efficiency.

Hospital coding guidelines also encourage coders to stay current with the latest coding regulations and industry changes to ensure that all codes are accurate and up-to-date.

The Role of Technology in Improving Hospital Coding Accuracy

Technology can play a critical role in improving hospital coding accuracy by automating, streamlining, and enhancing the coding workflow. Some examples of technology that can help with hospital coding include:

• Computer-assisted coding (CAC) or hospital coding software that uses natural language processing (NLP) to analyze clinical documentation and generate suggested codes allows coders to access and review clinical information in a single platform. 

• Artificial intelligence and machine learning tools can learn from previous coding decisions and provide feedback and recommendations to coders.

• Blockchain technology can create a secure and transparent ledger of coding transactions and prevent fraud and errors.

The Benefits of Error-Free Claims

Submitting error-free claims provides patient registration and cash flow and reduces claim rejections. Additionally, error-free claims may eliminate the risk of audits and investigations by insurance companies and government agencies. Overall, patient satisfaction improves by ensuring that claims are processed quickly and accurately.

Revenue Maximization and Compliance

Revenue integrity is the practice of translating patient experiences to revenue in a healthcare organization while avoiding revenue leakage or compliance issues. Revenue maximization starts with the front desk and the registration and enrollment process; additionally, other steps are necessary to improve revenue while complying with regulatory requirements and hospital policies.

• Ensure staff are well trained and motivated for patient enrollment in appropriate insurance programs and collection of minimum visit payments. 

• Monitor changes in payer mix and reimbursement rates. 

• Employ certified and experienced coders.

• Conduct regular audits and review to identify and correct errors or discrepancies.

• Use top-of-the-line hospital coding software to automate and streamline your processes.

• Communicate with physicians to ensure accurate and complete documentation of medical services.

By improving revenue cycle processes with these key guidelines, hospitals can strive to boost revenue while complying with government regulations.

Coronis Health and Hospital Coding

Hospital coding accuracy is essential for ensuring that claims submitted to payers are error-free and compliant with the latest regulations. By following best practices, your hospital and your patients can benefit from a streamlined coding process with the help of technology, expertise in coding, and reduced errors, denials, and claim rejections. Coronis Health has a team of dedicated experts in hospital medical coding revenue cycle management. To find out how you can integrate the best hospital billing and coding processes into your organization, contact Coronis Health for more information. 

from
https://www.coronishealth.com/blog/hospital-coding-accuracy-best-practices-for-error-free-claims/

Ghost in the Machine: Payer Programming Auto-Denies Claims?

In May of 1999, Vice President Al Gore made a startling assertion to CNN’s Wolf Blitzer: “During my service in the U.S. Congress, I took the initiative in creating the Internet.” Wow! I guess that’s why we talk in terms of computer Al-Gor-ithms to this day (cue the “bah-dah-boom” on the snare and cymbal). Of course, regardless of the term’s origin, an algorithm is a very important component in today’s modern technology. Without it, so much of our math, science and computing power would be impossible. So, what is an algorithm, anyway? According to one definitional description, it is “a process or set of rules to be followed in calculations or other problem-solving operations, especially by a computer.” So, in one way, we can look at this as another means of describing programming.

At Coronis Health, our billing and coding system is based, in part, on a robust “rules engine,” containing thousands of rules that have been programmed into the system to prevent inappropriate or non-compliant claim submissions. It’s a set of algorithms designed to maximize precision in the billing and coding process. So, in many cases, the use of algorithms can be a positive thing. But, in recent days, one major health insurer has been accused of using its own algorithm to put a massive stop on payments.

A Spooky Situation

CBS News and other high-profile media outlets are reporting that Cigna Healthcare is being accused of using a deliberately programmed algorithm to review—and often reject—hundreds of thousands of patient health insurance claims. In a class-action lawsuit, filed in the U.S. District Court in Sacramento, plaintiffs allege that Cigna has engaged in a scheme that violates California state law, which requires that insurers conduct a “thorough, fair and objective” investigation into each patient claim. The suit contends that Cigna is instead relying on an algorithm, designated as “PXDX,” to essentially deny claims on an almost automatic and widespread scale. In utilizing this methodology, it is alleged that Cigna is able to reduce its labor costs by drastically reducing the time needed by those hired to look at each claim.

Here are some examples provided by CBS of those who claim to have been unfairly affected by Cigna’s processes:

• One California woman with Cigna health insurance, underwent an ultrasound ordered by her doctor because of concerns about ovarian cancer. The ultrasound found a cyst on her left ovary. Cigna denied her claim for the ultrasound and a follow-up procedure, claiming neither were medically necessary, which left her on the hook for $723 in costs for the two ultrasounds.
  
• Another Cigna patient in California had a vitamin D test to check for a deficiency, a procedure that was ordered by her doctor. Cigna denied her claim but didn’t provide an explanation about why the test was rejected, according to the suit.

Plaintiffs allege that Cigna’s claims review panel—made up of physicians—is able to “instantly reject claims on medical grounds without ever opening patient files, leaving thousands of patients effectively without coverage and with unexpected bills.” It’s claimed that, over a period of two months in 2022, Cigna doctors denied over 300,000 requests for payments using the PXDX algorithm, spending an average of only 1.2 seconds “reviewing” each claim.

Larger Implications

The litigation highlights what some see as the growing use of algorithms and artificial intelligence to perform tasks that were once routinely handled by human staff. In the healthcare context, one wonders whether a computer program can provide the kind of “thorough, fair and objective” analysis that a human medical professional would bring to the claim evaluation process. Is this what consumers of healthcare services can expect in the years to come—a sort of Terminator 2 approach to their medical claims?

To be fair to Cigna, the insurance giant does challenge the allegations being levied against it. In a statement to CBS News, Cigna called the lawsuit “highly questionable” and asserted:

Based on our initial research, we cannot confirm that these individuals were impacted by PXDX at all. To be clear, Cigna uses technology to verify that the codes on some of the most common, low-cost procedures are submitted correctly based on our publicly available coverage policies, and this is done to help expedite physician reimbursement.

However, a ProPublica exposé on Cigna’s claims review process back in March stated the following:

Medical directors are expected to examine patient records, review coverage policies and use their expertise to decide whether to approve or deny claims, regulators said. This process helps avoid unfair denials. But the Cigna review system that blocked [the patient’s] claim bypasses those steps. “Medical directors do not see any patient records or put their medical judgment to use,” said former company employees familiar with the system. Instead, a computer does the work. A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments. Company doctors then sign off on the denials in batches, according to interviews with former employees who spoke on condition of anonymity.

The result of these revelations? Patients made a federal case out of it. And who can blame them if these allegations have any basis in truth? If a major insurer did mandate such a change in policy and if hundreds of thousands of claims were automatically denied due to some arbitrary algorithm, then what is to prevent other health insurers to follow the same course? The coming ruling on this case now before a federal district court may be the decisive factor in determining whether or not the future will involve ghosts in the machines.

With best wishes,

Chris Martin
Senior Vice President—BPO

from
https://www.coronishealth.com/blog/ghost-in-the-machine-payer-programming-auto-denies-claims/

The Role of Technology in Streamlining Hospital Billing Processes

The fast pace of the healthcare industry demands that hospitals stay in tune with not only the delivery of care but also the technology it uses to capture the necessary information for accurate and timely billing, coding, and payment submission. Hospital medical billing can also be a source of errors, fraud, and inefficiencies that affect both providers and patients. Understanding the complex nature of hospital billing requires a firm grasp on how technology can help to streamline processes and improve the quality and accuracy of healthcare delivery.

Benefits of Technology in Hospital Billing 

Technology has transformed many aspects of healthcare, including the billing and coding process for large hospital systems and small rural centers alike. It provides efficiency and accuracy they need to navigate the complex hospital billing process, which can benefit both healthcare providers and patients, while increasing revenue for hospitals. Here are some of the benefits of technology in hospital billing processes:

• Refined coding for improved efficiency and reduced errors in claim submissions
• Automated billing processes to enhance speed and streamline operations
• Robust collections strategies to maximize revenue while prioritizing positive patient experiences
• Reduced staff stress and increased time allocation for superior patient care

Other benefits of Coronis Health’s technology-focused approach include that it:

• Delivers data-driven insights for future planning
• Provides a platform for recording and storing patient medical history, diagnosis, and treatment
• Reduces errors and duplication of data
• Quickly verifies insurance eligibility and status of patients, which can prevent claim denials and delays
• Automates coding and billing, saving time and resources
• Ensures compliance with current regulations and standards
• Tracks and monitors the revenue cycle, optimizing cash flow and financial performance
• Provides transparent and timely billing information to enhance the patient experience
• Reduces the administrative burden
• Enables remote access to billing data
• Improves communication and collaboration among hospital staff

Software specifically designed for hospital billing and coding is a powerful tool that can improve efficiency and reduce overhead costs, but it also requires proper implementation, training, and maintenance. Hospital providers should choose the right technology solutions that suit their needs and goals, and leverage them to deliver quality care and service to their patients.

Hospital billing and coding pull information from the documentation in a patient chart for the purpose of submitting claims to insurance payers for reimbursement. This process is complex, time-consuming, and often results in missed revenue due submission errors. 

At Coronis Health, we use advanced hospital billing software to help streamline your hospital’s processes, reduce errors, and relieve your administrative burden. 

Software Agnostic EHR Integration

Coronis Health takes a software agnostic approach to technology integration that ensures your hospital doesn’t have to learn a new system. We integrate with your EHR system for a seamless transition that eliminates disruptions in your workflow. 

With our technology-driven approach, your hospital can experience improved productivity, reduced administrative burden, and increased revenue generation. Our advanced software not only streamlines the billing process but also provides valuable insights and analytics, empowering your hospital to make data-driven decisions for financial optimization.

Our technology-driven approach ensures all of your RCM processes are overseen by a single source that includes:

• Charge Entry
• Billing
• Credit Balance Accounts
• Early Out
• Collections
• A/R Follow-Up
• Payment Posting
• Pre-registration
• Scheduling
• Denial Management
• Patient Collection/Self Pay
• Bad Debt

Challenges in Implementing Technology in Hospital Billing

Implementing technology in hospital medical billing is not without challenges. With the right approach and diligence, hospitals can overcome the significant challenges they may face when adopting hospital billing services.

• User and information technology support: Training and onboarding is essential. Hospitals must train staff and provide IT support for new systems to prevent errors and low productivity. 

• Compliance and data integrity: Hospitals must adhere to regulations such as HIPAA, ICD-10, and CPT and ensure accurate and secure data to avoid legal issues or loss of trust.

• Ease of use and interoperability: Compatibility ensures efficient workflow and secure data exchange.

The Impact of Technology on Hospital Billing Procedures

Technology can greatly influence hospital billing. Billing and coding software streamlines workflows, reduces errors, improves patient service, and increases revenue. Technology can enhance medical billing and coding in the following ways:

• Automation: Technology automates the billing processes to save time, reduce manual work, and identify mistakes. This includes data collection, coding, billing, revenue tracking, and business monitoring.
  
• Compliance: With the robust technology that Coronis Health offers, hospitals can implement automated compliance checks that validate billing codes against coding guidelines and regulations. This helps identify potential compliance issues, such as incorrect coding or unbundling, before claims are submitted, reducing the risk of non-compliance and associated penalties.

• Artificial intelligence (AI): AI may improve medical billing accuracy, speed up processing, automate tasks, prevent claim denials and optimize reimbursement.

• Digital transformation: Technology can reduce paperwork and store data securely in the cloud. This can help healthcare staff to access information faster and provide better service to patients. Technology can also help to record financial transactions automatically and provide accurate financial information.

The Future of Technology in Hospital Billing

The future of technology in hospital medical billing is promising and exciting. Technology has the ability to improve the quality, safety, and efficiency of healthcare, as well as reduce costs and errors. The future of billing and coding for hospitals is being shaped by these trends and innovations:

• Robotic Process Automation (RPA): The future of hospital billing embraces the use of robotic process automation, which involves the deployment of software robots to automate repetitive and rule-based tasks. RPA can handle tasks such as data entry, claims processing, and eligibility verification with high accuracy and efficiency. By automating these routine processes, hospitals can free up staff time, reduce errors, and optimize operational workflows, ultimately leading to improved billing outcomes and cost savings.

• Data sharing: Technology enables secure data sharing across providers and platforms to improve coordination, avoid redundancy, and enhance patient engagement and satisfaction.

• Value-based payments: Technology supports the transition to value-based payment models, helps measure patient outcomes and aligns incentives among stakeholders. 

• Predictive analytics: AI and machine learning (ML) can analyze data to generate insights that improve decision making and care delivery, identify patterns and trends, enhance performance and personalize care.

Technology is transforming the field of hospital billing and creating new opportunities for professionals who have the skills and knowledge to adapt to the changing landscape. With the guidance of Coronis Health, you’ll have full support from our tech department and Chief Technology Officer to direct you on the path to success. Don’t let the complexities of hospital billing stunt the growth and prosperity of your organization. Contact Coronis Health today to find out how your hospital can benefit from using the technology it needs to step into the future of efficiency in the fast-paced healthcare industry. 

from
https://www.coronishealth.com/blog/the-role-of-technology-in-streamlining-hospital-billing-processes/

2024 PFS Proposed Rule: Implications for Chronic Pain Providers

Summary

The 2024 PFS proposed rule contains stipulations that will affect chronic pain practitioners, if finalized. Provisions involving E/M services, telehealth and discarded drugs are specifically highlighted in today’s alert. 

Like every year, the Centers for Medicare and Medicaid Services (CMS) generates new proposals that will affect the practices of medical professionals throughout the country. The Medicare Physician Fee Schedule (PFS) Proposed Rule for 2024 is no different. We’ve already shared in a previous alert what the rule proposes as it concerns the anesthesia specialty, generally, as well as the RBRVS conversion factor (hint: it’s lower next year). Today’s article will focus specifically on those issues most likely to have implications for chronic pain practices.

New Add-On Code

The rule for 2024 proposes to implement a separate add-on payment for healthcare common procedure coding system (HCPCS) code G2211. According to CMS, “This add-on code will better recognize the resource costs associated with evaluation and management (E/M) visits for primary care and longitudinal care of complex patients.” Generally, it will be applicable for outpatient office visits as an additional payment, recognizing the inherent costs clinicians may incur when longitudinally treating a patient’s single, serious or complex chronic condition. The add-on code would not be billed with a modifier that denotes an office and outpatient evaluation and management visit that is itself unbundled from another service (e.g., a procedure where complexity is already recognized in the valuation).

The extent to which longitudinal care, for example (and, by extension, this new add-on code), will apply to the specialty of pain management is not entirely certain at this time. However, we should have greater clarification on this matter should it be addressed in the 2024 PFS final rule, which is expected to be published in November.

Split Visits

As you will recall, split (or shared) E/M visits refer to those clinical encounters provided in part by physicians and in part by other practitioners in the hospital or other facility setting. For 2024, CMS is proposing a delay in the implementation of its definition of the “substantive portion” as more than half of the total time through at least December 31, 2024. Instead, the proposed rule maintains the current definition of substantive portion for 2024 that allows for use of either one of the three key components (history, exam or MDM) or more than half of the total time spent to determine who bills the visit.

Telehealth Services

The proposed rule adds health and well-being coaching services to the Medicare Telehealth Services List on a temporary basis for 2024, and it adds Social Determinants of Health Risk Assessments on a permanent basis. In addition, the rule would implement several telehealth-related provisions of the Consolidated Appropriations Act, 2023 (CAA, 2023), including the following:

• The temporary expansion of the scope of telehealth originating sites for services furnished via telehealth to include any site in the United States where the beneficiary is located at the time of the telehealth service, including an individual’s home; and
• The expansion of the definition of telehealth practitioners to include qualified occupational therapists, qualified physical therapists, qualified speech-language pathologists and qualified audiologists.

Pursuant to the rule, telehealth services furnished to people in their homes will be paid at the non-facility PFS rate to protect access to mental health and other telehealth services by aligning with telehealth-related flexibilities that were extended via the CAA, 2023.

As to supervision, the rule will continue to define direct supervision as permitting the presence and immediate availability of the supervising practitioner through real-time, HIPAA-compliant, audio and video interactive telecommunications through December 31, 2024.

Opioid Treatment Programs (OTPs)

The 2024 proposed rule would extend current flexibilities for periodic assessments that are furnished via audio-only telecommunications through the end of 2024. It allows opioid treatment programs (OTPs) to bill Medicare under the Part B OTP benefit for furnishing periodic assessments via audio-only telecommunications when video is not available to the beneficiary, to the extent that (a) use of audio-only communications technology is permitted under the applicable SAMHSA and DEA requirements at the time the service is furnished, and (b) all other applicable requirements are met.

Refunds for Discarded Amounts

In the 2023 PFS final rule, CMS had adopted many policies to implement section 90004 of the Infrastructure Act. Among them were the following: (a) the definition of “refundable single-dose container or single-use package drug,” which also specifies certain exclusions; (b) reporting requirements for use of the JW modifier to report discarded amounts of drugs from single-dose containers and the use of the JZ modifier for such drugs with no discarded amounts; (c) an increased applicable percentage of 35 percent for a category of drugs with unique circumstances; and (d) a dispute resolution process.

In the 2024 proposed rule, implements the following:

• Timelines for the initial and subsequent discarded drug refund reports to manufacturers;
• The method of calculating refunds for discarded amounts from lagged claims data;
• The method of calculating refunds when there are multiple manufacturers for a refundable drug;
• Increased applicable percentages for certain drugs with unique circumstances;
• An application process by which manufacturers may request an increased applicable percentage for a drug with unique circumstances; and
• Modification to the JW and JZ modifier policy for drugs payable under Part B from single-dose containers that are furnished by a supplier who does not administer the drug.

To review the full 2024 PFS proposed rule, you can click on the following link: 2023-14624.pdf (federalregister.gov).

If you have any questions on this topic, please reach out to your account executive.

With best wishes, 

Rita Astani
President—Anesthesia

from
https://www.coronishealth.com/blog/2024-pfs-proposed-rule-implications-for-chronic-pain-providers/