All Aboard! New Transparency Bill Heading Down the Track

We’re on a roll—like a runaway freight train. This is the third alert in a row that we are bringing on the topic of hospital price transparency. Though, at this point, it may seem like an obsession on our part, it’s really more of a reflection of how much the transparency issue has been in the news of late. In the last two alerts, we covered the recent changes to the transparency rules and then provided you the results of a “secret shopper” operation that uncovered price discrepancies. Now, we have another reason to jump on the transparency train: a new bill circulating in Congress.

The Latest Locomotive

Earlier this month, a bipartisan group of legislators in Washington, D.C. submitted a new bill entitled the “Lower Costs, More Transparency Act (LCMTA).” According to a statement released by the U.S. Energy and Commerce Committee, along with two other committees (Ways and Means, Education and the Workforce), LCMTA is designed to increase healthcare price transparency and lower overall costs for patients and employers. The bill incorporates provisions advanced by leaders of all three committees, which may be an early indication of its chance for passage—at least in the House of Representatives. According to Ways and Means Chairman Jason Smith:

The Lower Costs, More Transparency Act will bring honesty and clarity to the cost of health care by requiring health insurers, hospitals, and PBM middlemen to be transparent about the prices they charge patients. It will increase access to care for patients by combating consolidation in health care delivery that drives up costs by shining a light on the increasingly common practice of vertical integration. Transparency will also give patients confidence knowing what they will pay for their health care while creating incentives to lower prices.

The chair and ranking member of the other two committees provided similar sentiments in their statements, as well.

From Engine to Caboose

A press released issued by the legislators who introduced the bill provided practical examples of how LCMTA would help the American healthcare consumer, at least from their perspective. These include the following:

Increases Price Transparency Throughout the Health Care System for Patients 

• Empowers patients to shop for health care and make informed health care decisions by providing timely and accurate information about the cost of care, treatment, and services.
• Requires health care price information from hospitals, insurance companies, labs, imaging providers, and ambulatory surgical centers to publicly list the prices they charge patients, building upon the Trump administration price transparency rules.
• Lowers costs for patients and employers by requiring health insurers and pharmacy benefit managers (PBMs) to disclose negotiated drug rebates and discounts, revealing the true costs of prescription drugs.

Addresses the Cost of Prescription Drugs

• Lowers out-of-pocket costs for seniors who receive medication at a hospital-owned outpatient facility or doctor’s office.
• Expands access to more affordable generic drugs.
• Equips employers with the drug price information they need to get the best deal possible for their employees.

Supports Patients, Health Care Workers, Community Health Centers, and Hospitals

• Fully pays for investments into programs that strengthen the health care system by:
  • Funding Community Health Centers, which are crucial for patients in rural and underserved areas
  • Supporting training programs for new doctors in communities
  • Preserving Medicaid funding for hospitals that take care of uninsured and low-income patients
  • Extending funding for research to find better treatments and a cure for diabetes, which affects more than 37 million Americans

Going Off the Rails?

While supporting parts of the bill, the American Hospital Association (AHA), was clearly not pleased with every provision of LCMTA. The AHA’s executive vice president, Stacey Hughes, issued a letter to House leaders in mid-September, outlining some of the organization’s concerns:

The AHA supports the suspension of the Medicaid disproportionate share hospital (DSH) reductions for two years and appreciates your work to include this provision, however hospitals and health systems strongly oppose efforts to include permanent site-neutral payment cuts. In addition, the AHA has serious concerns about the added regulatory burdens on hospitals and health systems from the provisions to codify the Hospital Price Transparency Rule and to establish unique identifiers for off-campus hospital outpatient departments (HOPDs).

The AMA communication contained other comments about the bill that were less than glowing. To see the entire AMA letter concerning the proposed legislation, please click on the following link: AHA Comments on House Proposed “Lower Costs, More Transparency Act” | AHA. So, while not everyone is completely on board with this latest transparency measure, this train is out of the station and is so far on track. We’ll have to wait and see if it reaches its intended destination.

With best wishes,

Chris Martin
Senior Vice President—BPO

from
https://www.coronishealth.com/blog/all-aboard-new-transparency-bill-heading-down-the-track/

Is Big Better? The Age-Old Question for Anesthesia Providers

Summary

Today’s anesthesia providers have choices insofar as the kind of practice they want to join. Each type of practice has its benefits and drawbacks. These determinants are often based on group size. Is joining a bigger practice the right choice for all? Today’s alert digs into that question.

Is big better when it comes to anesthesia practices? The answer depends on who is asking the question and what the goals and objectives of the practice are. Merger mania has certainly dominated the marketplace for decades, leaving many providers with the impression that only the largest entities will survive the challenging currents of American healthcare. The prevailing perspective is that small group practices are dinosaurs en route to extinction. The reality is that there has never been such turmoil in the specialty. So many practices have either merged, been bought out or simply ceased to exist. Hospital employment seems to be claiming an ever-growing percentage of providers. Paradoxically, this may be an especially opportune time for small practices willing to partner with their hospital administrations. After all, the key to success in today’s market is customer service.

The Main Objectives

Let us begin by asking a very fundamental question: what is the purpose of an anesthesia practice? In basic terms, it is an efficient structure for the provision of all the anesthesia services required by a facility. It must have a structure and governance that will ensure consistency and quality of care. Beyond this, though, there are the expectations of the providers who must decide whether this is the best organization to work for. Most providers would agree they have three main objectives:

1. Income
2. Security
3. Quality of life

When all three can be met with a reasonable degree of certainty, most providers are content and productive. Perceived challenges and compromises on any level can result in frustration, dissatisfaction and often termination. Herein lies the explanation for so much of the current mobility of anesthesia providers. Anesthesia residents are usually advised to pick the practice that will support their personal and professional objectives till they retire; in other words, pick the horse that will stay the course. The reality is that an ever-growing number of practices simply do not meet the test, leaving so many providers wondering what they should do.

Sizing up the Practice

The fact is that size is often a confounding factor. All practices have their pros and cons: small practices must contend with the challenging and often mercurial requirements of hospital administrations. Big practices may have more options and better resources, but they are no less challenged by the current market for healthcare. There is a saying in business that if you want to solve a problem, create a bigger one. While small practices must generate enough revenue to recruit and retain a sufficient number of qualified providers to meet the service expectations of a given administration, today’s mega-groups must accomplish this across a broad spectrum of practices and practice types. Small practices worry about losing their contract, but large practices lose contracts all the time as they compete in an increasingly competitive market.

Merger mania is often driven by a blind belief in the notion that large practices have more leverage to negotiate better rates with key insurance plans. It is true there are notable examples of mega-groups that have accomplished this with some of their insurance plans. Let us not forget, however, that a few good contracts when viewed through the lens of the practice’s payer mix does not produce a cash windfall. Positive PPO contract rates are always offset by the significantly discounted Medicare and Medicaid payment rates. And the percentage of patients covered by Medicare is growing as the American population ages. Victories on this front are fewer and further apart, even among the nation’s largest anesthesia companies.

The simple fact is that most practices need the financial support of their facilities to balance their budgets. Hospital subsidies are achieving new levels heretofore never envisioned. And this may be one aspect of practice management companies where the big players excel, although such accomplishments often involve the services of outside independent management consultants available to all practices.

A Matter of Perspective

The notion of practice security depends on one’s perspective. If the goal is to buy a house, raise a family and become part of a community, then small practices in isolated communities have the best chance of success. The large practices may require you to move from one facility to another, especially if they lose a contract. National staffing companies may need you to relocate to start new practices as they gain new contracts. What they guarantee you is employment but not necessarily a specific job. For many providers, this is a plus; but, for others, it’s a considerable detriment.

Quality of life is a very personal thing. There was a time when anesthesia group practices consisted of like-minded individuals who shared a core set of values and approach to the provision of care. Many practices included a number of providers who had trained together. Such practices were often referred to as professional fraternal organizations because they functioned more like clubs than commercial entities. As the market has evolved, however, these clubs have morphed into serious businesses, and the culture and nature of the role of each provider has changed dramatically. This is especially true of today’s mega-groups which are looking for qualified providers to fill particular job descriptions. It used to be that providers took particular pride in what occurred inside the operating room, but now their future depends on what occurs outside the OR, in the C-suite.

What makes for contented and productive providers? Most will tell you it is fair compensation, a reasonably secure work environment and the ability to balance work and home. The truth is that the larger the organization, the harder it is to balance all three. The biggest complaint of many employees of the nation’s largest practices is lack of constituency; they have little or no input with regard to the factors that determine their income and lifestyle. The larger the organization the more providers are dependent on the quality and effectiveness of management.

As individuals, all anesthesia providers must ultimately ask themselves the following questions: do they want to be master of their own destiny for better or worse, or do they want the security of being an employee in a large organization that will deploy them wherever or however they may be needed? It is not a simple decision, nor are there necessarily clear answers. As is true of providing anesthesia, sometimes no amount of preparation and planning guarantees a perfect outcome.

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/is-big-better-the-age-old-question-for-anesthesia-providers/

Holmes Heads to the Hospital: Price Transparency Meets Price Inconsistency

Sir Arthur Conan Doyle would have been quite pleased with the story coming out of a respected medical publication this month. It was as if his own creation—the character we all know as Sherlock Holmes—had cracked his latest case in the usual spectacular fashion. Undercover operatives, corporate intrigue and the circumvention of federal law—what more could the public ask for in its pursuit of the next best-selling crime thriller?

On the Trail

According to a study published in the Journal of the American Medical Association (JAMA) this month, a sizeable percentage of hospitals were found to be advertising different prices for medical services online versus over the phone. As we stated in last week’s alert, the Hospital Price Transparency regulation establishes enforceable guidelines by which hospitals must reveal the standard charges they have established. We went into great detail on the penalties facilities face for ignoring or openly flouting this regulation. That’s what makes the investigation published in JAMA all the more alarming.

Researchers out of the University of Texas Medical Branch, who issued their findings to JAMA, conducted a “secret shopper” operation. Like an undercover detective, they received information on cash prices for 60 U.S. hospitals between August and October of 2022, based on online searches. The services targeted were vaginal childbirths and MRIs of the brain. The team then called each of these facilities, requesting the lowest cash prices for these same medical services.

The findings confirmed those of previous research that demonstrated a wide divergence in pricing between different hospitals, and even within the same hospital based on a patient’s insurer. For example, the new study found online prices for vaginal childbirth posted by top-ranked hospitals ranged from $0 to $55,221. The results also suggest that hospitals may not even be aware that their own prices reflect a wide discrepancy between their published online rates and those they provide potential patients over the phone.

Magnifier in Hand

Of the 60 hospitals reviewed, 22 were able to provide both online price and telephone quotes for vaginal childbirth. Those prices were within 25 percent of each other at just 10 hospitals. However, nine hospitals had internal price differences of 50 percent or more. Forty-seven hospitals were able to provide prices online and by telephone for a brain MRI. The prices for this service were within 25 percent of each other at 31 hospitals. Twelve hospitals had differences of 50 percent or more. Online and telephone prices completely matched in nine hospitals for a brain MRI. For vaginal childbirth, they completely matched at three.

For example, researchers found five hospitals with online prices greater than $20,000 for a vaginal childbirth, but telephone prices of less than $10,000. For a brain magnetic resonance imaging scan, two hospitals said the cost was more than $5,000 over the phone, but the price tag was $2,000 online.

According to those conducting the investigation:

The findings provide evidence of hospitals’ continuing problems in communicating their own prices to patients. These results illustrate the promise of, and substantial barriers to, translating newly available hospital price data into actionable information that ultimately facilitates comparison shopping.

Price discrepancies could be due to a variety of factors, according to the study:

• Hospital billing office staff might not have understood the inquiry.
• Hospitals may not adequately train staff.
• Hospitals might not be aware of its online price estimator tool.

Researchers also said that the lack of correlation may simply “reflect a chaotic and disorganized pricing structure.”

Solving the Case

The Centers for Medicare and Medicaid Services (CMS) has authorization to fine hospitals up to $2 million for failing to post prices. However, according to a September report in HealthcareDive, “there is no formal mechanism for the agency to audit or penalize hospitals that post incorrect or misleading medical costs.” If true, there may be no current or urgent impetus for hospitals to resolve the wide variations between online and over-the-phone prices. Nevertheless, such discrepancies cannot be a good look, and hospitals will ultimately need to address the issue.

The first step to resolving these embarrassing inconsistencies will be to have appropriate personnel undertake a regular review of prices found online for the services that require transparency and ensure that they accurately reflect the price that is given over the phone. Only certain individuals should have the responsibility to give out prices verbally. Coordination of the responsible individuals should be routine rather than rare. The second step is to ensure that the administration makes this coordination of pricing information a priority through (a) regular meetings where such communication is on the agenda, (b) and training, where indicated. No one wants their institution to be accused of giving out conflicting information. That undermines the public’s faith in such institutions, and we have enough of that to deal with in our everyday lives. Furthermore, studies like this appearing in prestigious journals such as JAMA will not escape the attention of regulators at CMS. The secret shopper operation may cause the agency to look at introducing new rules to penalize not only those who fail to publish prices but who fail to publish them accurately.

With best wishes,

Chris Martin
Senior Vice President—BPO

from
https://www.coronishealth.com/blog/holmes-heads-to-the-hospital-price-transparency-meets-price-inconsistency/

Understanding the Importance of Medicare Provider Enrollment

Summary

Running a successful anesthesia or chronic pain practice is like a juggler who has added one too many balls to his routine. If you don’t promptly address each clinical or business imperative that arises, utter failure may ensue. One of these imperatives involves Medicare provider enrollment. This is one ball you can’t afford to drop.

Though often overlooked, provider enrollment can have a major impact on the overall success of a medical group practice. Navigating the enrollment process can be tricky, especially when one considers that each carrier has its own unique set of regulations concerning who can participate and how the enrollment process must be completed.

The Priority

Due to Medicare’s strict requirements and screening processes, it is becoming increasingly common for various payers, including many states’ Medicaid programs, to require providers to enroll with Medicare prior to requesting participating group/provider status. Thus, even if Medicare is not a significant part of the group’s payer mix, Medicare enrollment may still be vital for entering other payers’ networks. For example, a pediatric group that plans to bill Medicaid of Texas must first be enrolled with Medicare before they can apply to be a Texas Medicaid participating provider.

The Centers for Medicare and Medicaid Services (CMS) is the federal agency that is responsible for ensuring that all Medicare regulations are being followed. Provider enrollment is no exception in this regard, and CMS has a team that focuses solely on provider enrollment. This team is responsible for protecting the program by ensuring that Medicare approved groups/providers meet all requirements to participate in the program. CMS has implemented many checks and balances into their enrollment process to weed out ineligible groups/providers.

The Process

Even with their checks and balances, enrolling in Medicare should not be an overly difficult process. Starting the enrollment process well ahead of providing services will help ensure a favorable effective date and reduce the risk of non-covered claims. Understanding how an organization is set up is vital for the completion of the enrollment process. The type of enrollment that needs to be completed will depend on the specific business structure. Submitting the wrong enrollment form/information will delay the process and could impact the assigned effective date.

New sole proprietorships or sole owner groups should complete the 855I form to enroll the entity with Medicare. In contrast, partnerships, limited partnerships, LLCs, joint ventures and all types of corporations or government owned entities would complete form 855B. Individuals can be added to (a) sole owner practices, and (b) any group that enrolls using 855B form. The difference between enrolling a practice using an 855I and 855B is the reporting of ownership information. When one individual owns the whole practice, Medicare can utilize the 855I to verify that the owner meets Medicare requirements. When a medical group has more than one owner, Medicare will verify that any individual that has five percent or more ownership meets the requirements of participation.

Submitting accurate ownership information is a strict requirement. Ownership information has become a focal point for CMS’ Provider Enrollment and Oversight Group in recent years. In the fall of 2021, CMS added a Provider Ownership Verification Contractor. This third-party organization verifies that the ownership information on the application matches external sources, such as the secretary of state. If inaccuracies are found, there will be a delay in the processing. If an owner was not reported and that owner is ineligible to participate in the Medicare program, Medicare may issue an enrollment bar for up to 10 years for falsifying information to gain benefits.

The Premises

Practice locations reported on the application should match the address as listed by USPS. Provider Enrollment, Chain and Ownership System (PECOS) is Medicare’s provider enrollment software solution that interfaces with USPS website. If there is an address mismatch, a Medicare site visit may be conducted. This site visit will focus on the facility being operational and will confirm that the group practice does, in fact, provide services within the facility. If there is a notice that a site visit will be forthcoming, any public facing employee must be aware of the group’s legal business name, which often differs from the facility name.

The Providers

All individual practitioners must first be enrolled with Medicare in the state in which the provider practices using the 855I application. If providers are working in multiple states, the provider will need to enroll in each state. Medicare is going to verify that the provider’s name on the application matches the provider National Plan and Provider Enumeration System (NPPES) profile and license.

A provider is linked to an enrolled group utilizing the 855I application. Both the provider and group authorized official will need to sign to add a provider to a group. A provider can be removed from a group by submitting an 855I along with either the provider or authorized representative signature.

All group and provider enrollment applications will ask if the providers/owners have an adverse legal action history. It is important to accurately report all adverse legal action with applicable attachments. CMS has included the regulations of what actions need to be reported on both the 855B and 855I applications. Submitting inaccurate adverse legal history can cause CMS to issue an enrollment bar.

The Period

Enrolled groups and providers will be required to revalidate their enrollment at least once every five years. Medicare can issue an off-cycle revalidation notification at any time. These notifications will be sent to at least two addresses: the special payments address and the correspondence address. If these are the same address, then a notification will also be sent to the primary facility. Failure to revalidate will result in payment holds. Continued failure will result in deactivation, and there will be a lapse in coverage from the deactivation date until the date Medicare received the re-enrollment request.

All enrolled providers and groups have agreed to maintain their enrollment records with Medicare by providing updates within 90 days of the change, including any provider who becomes employed or resigns. Adverse legal action, ownership changes, and locations additions/terminations must be reported within 30 days. Failure to report changes can result in termination from the program. Depending on the situation, Medicare may also issue an enrollment bar.

———

In summation, reviewing each Medicare application prior to signing, and verifying that all information is correctly documented, will help avoid any Medicare enrollment mishaps. Keeping your enrollment record updated on any change of information will help safeguard continued enrollment. So, as one can readily see, provider enrollment—especially as it concerns Medicare—will have a direct impact on the group’s ability to succeed over the long haul.

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-importance-of-medicare-provider-enrollment/

Opening up the Blinds: Transparency Rules for Hospitals

A few months ago, the Centers for Medicare and Medicaid Services (CMS) published a fact sheet that outlines process updates the agency is making to increase compliance with the hospital price transparency requirements. As our readers may recall, the government’s hospital price transparency requirements are authorized by section 2718(e) of the Public Health Service Act, which essentially requires each hospital to make its standard charges known to the general public. 

Today’s article acts to summarize the CMS fact sheet and seeks to remind our readers that this is a topic that CMS is taking seriously. It will behoove hospital administrators, therefore, to carefully consider the enforcement actions CMS outlines below for non-compliant facilities.

Reciting the Regs

The Hospital Price Transparency regulation establishes enforceable guidelines by which hospitals must reveal the standard charges they have established. The price transparency regulation defines several types of standard charges, including:

• Gross charges (as found in hospital chargemasters, which is the list of all individual items and services maintained by a hospital for which the hospital has established a charge, absent any discounts);
• Discounted cash prices (the charge that applies to an individual who pays cash or cash equivalent for a hospital item or service); and
• Charges negotiated between the hospital and third-party payers.

Hospitals are required to make these standard charges public in two ways: (a) a single comprehensive machine-readable file with all standard charges established by the hospital for all the items and services it provides; and (b) a consumer-friendly display of standard charges for as many of the 70 CMS-specified shoppable services that are provided by the hospital, and as many additional hospital-selected shoppable services as is necessary for a combined total of at least 300 shoppable services. This requirement can be satisfied through the release of a shoppable services file or by offering a price estimator that generates a personalized out-of-pocket estimate that takes into account the individual’s insurance information.

Comprehensive Review Process

The CMS fact sheet makes clear that the government is keeping an eye on hospitals relative to the above requirements. Like Saint Nick, it intends to keep a running list of who has been naughty and nice. The agency maintains three primary avenues for monitoring and assessing hospitals’ noncompliance:

• Evaluating complaints made by the public;
• CMS’s review of individuals’ or entities’ analysis of noncompliance; and
• Internal audits of hospitals’ websites.

When initially evaluating complaints, if a hospital is associated with a sufficient number of allegations regarding “egregious violations” of the rule (such as failure to publish any machine-readable file), that case is prioritized for further scrutiny.

Enforcement Process Updates

The occasion of the CMS fact sheet on price transparency is a set of updated processes that CMS is now putting into effect. They include the following:

1. Requiring CAP completion deadlines. CMS will continue to require hospitals that are out of compliance with the hospital price transparency regulation to submit a corrective action plan (CAP) within 45 days from when CMS issues the CAP request. CMS will also now require hospitals to be in full compliance with the hospital price transparency regulation within 90 days from when CMS issues the CAP request, rather than allowing hospitals to propose a completion date for CMS approval which can vary.
2. Imposing CMPs earlier and automatically. CMS will now automatically impose a civil monetary penalty (CMP) on hospitals that fail to submit a CAP at the end of the 45-day CAP submission deadline. For hospitals that submit a CAP by the 45-day deadline but fail to comply with the terms of that CAP by the end of the 90-day deadline, CMS will re-review the hospital’s files to determine whether any of the violations cited in the CAP request continue to exist and, if so, impose an automatic CMP.
3. Streamlining the compliance process. For hospitals that have not made any attempt to satisfy the requirements, CMS will no longer issue a warning notice to the hospital and will instead immediately request that the hospital submit a CAP.

These enforcement updates will shorten the average time by which hospitals must come into compliance with the hospital price transparency requirements after a deficiency is identified to no more than 180 days, or 90 days for cases with no warning notice, and will complement future efforts.

Enforcement Actions to Date

The government is serious about forcing its price transparency requirements onto acute care hospitals and is determined to punish those facilities that fail to follow these requirements. According to its own fact sheet, CMS is able to leverage automation “to complete hospital reviews quickly, accurately, and consistently.” The agency reports that it has increased the number of comprehensive reviews conducted from around 35 per month to over 200 per month.

As of April 2023, CMS had issued more than 730 warning notices and 269 requests for CAPs. CMS had imposed CMPs on four hospitals for noncompliance, which are posted and made publicly available on the CMS website. Interestingly, the fact sheet claims that “every other hospital that was reviewed through a comprehensive compliance review has corrected its deficiencies or is in the process of doing so.” For more information on CMS’ price transparency regulations and enforcement actions, please visit Hospital Price Transparency | CMS.

With best wishes,

Chris Martin
Senior Vice President—BPO

from
https://www.coronishealth.com/blog/opening-up-the-blinds-transparency-rules-for-hospitals/

The Significance of Customer Service in Anesthesia

Summary

There is a tendency in anesthesia to think that all that matters is consistently good outcomes. Nothing could be further from the truth. Customer service is now the key to maintaining a strong and successful relationship with administration.

As anesthesia practices evolve and diversify, it becomes increasingly difficult to maintain a consistent level of customer service. While the quality of the anesthesia care provided may be exceptional for most patients, there is much more to an optimum relationship with administration than just good clinical outcomes. In the current environment, quality of care is often taken for granted; and it used to be that what happened in the operating room was all that really mattered, but times have changed. The anesthesia department has become a critical business partner.

Clinical Skills, People Skills

Administrations need their anesthesia providers to be exemplary members of the medical staff who work collaboratively with surgeons, nurses and the OR staff. They must ensure that every patient receives not only a comfortable and safe anesthetic but that the whole surgical experience leaves the patient satisfied and happy that they chose that particular facility. Unfortunately, experience has told us that even great clinicians do not always understand or appreciate the importance of their demeanor and attitude. The ultimate success of a practice has much more to do with what happens outside the operating room than within its four walls. 

The specialty of anesthesia is unique in many ways. The training of providers focuses on their diagnostic analysis, their clinical skills and their ability to evaluate all possible variables in the formulation of the anesthesia plan. As is often said, while the surgeon is only focused on a very small part of the patient’s anatomy, the anesthesia provider must see and manage the whole patient and his or her responses to the trauma of surgery. Anesthesia providers pride themselves on being vigilant monitors of body systems and problem-solvers. Each anesthetic is a unique formulation of the provider’s interpretation of patient concerns and expectations, the specific anesthetic requirements of the surgical procedure and the surgeon, and any other patient or operative factors that may apply.

By accepting a provider as a member of a practice, the management assumes the provider is competent and qualified to provide a quality experience. It is usually only exceptionally negative outcomes that cause the practice to question a provider’s qualifications and/or competence. While hospitals may require customer service questionnaires, it is the rare practice that performs any type of consistent or rigorous quality control. The prevailing philosophy of most practices can be likened to professional fraternal organizations, for which the primary objective is to protect each other. There is no greater challenge in most practices than the need to terminate a partner.

Quality Control

There are, of course, some notable exceptions to this. One of these was one of our large west coast clients that many years ago implemented a 360-degree review of all providers. Each provider’s annual review involved a compilation of questionnaire results from patients, surgeons, OR staff and other members of the practice. The medical director was responsible for the entire process and would meet with each provider to discuss strengths and weaknesses that should be addressed. Failure to address and improve negative findings would ultimately lead to termination of employment. 

While such a process might seem too complex and burdensome for the typical practice, this is the kind of quality control that most hospital administrators expect. As practices grow and as turnover rates increase, hospital administrators typically want to know how the practice is monitoring the consistency of customer service provided and what actions are being taken to ensure that it is consistently exemplary. The reason they prefer to contract with private practices is so that the anesthesia providers are held accountable for the specific terms of the agreement. Such a concept of customer service has been the hallmark of most successful businesses for years. Why should it be any different in medicine?

There is a common saying in business that one cannot manage what one does not measure. While businesses focus on each aspect of a process in terms of its impact on profitability—which obviously also applies to large anesthesia practices—the most important focus of anesthesia practices must be on their value proposition. Is every provider in every case enhancing the practice’s overall value proposition? Accountants may have erasers to fix their mistakes, but clinicians do not have such an option. Exceptions and outliers must be identified, assessed and addressed in such a manner that they do not recur. Provider profiling may seem anathema to many anesthesia providers, but it is an inevitable consequence of the current competitive market 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/the-significance-of-customer-service-in-anesthesia/

On a Roll: Another Victory for the TMA

For the fourth time in a row, a federal judge has sided with the Texas Medical Association (TMA) in its legal challenges to regulations that implement the federal No Surprises Act (NSA).  The TMA brought another one of its legal actions back in November, alleging that certain provisions of the NSA regulations inappropriately link providers’ payment to the qualifying payment amount (QPA).

The plaintiffs asserted that the U.S. Department of Health and Human Services (HHS) and the other federal departments empowered by the NSA to develop implementing regulations (collectively described hereinafter as “departments”) had crafted the regulations in such a way as to “skew negotiations in favor of health insurers so strongly that health insurers will force physicians out of insurance networks and physicians will face significant practice viability challenges, struggling to keep their doors open in the wake of the pandemic.”

Here Comes the Judge

In an August 24 decision, the U.S. District Court for the Eastern District of Texas disallowed several provisions related to the QPA. According to the American Hospital Association (AHA), which filed an amicus curiae brief supporting the TMA action:

The court specifically disallowed several regulatory provisions related to the QPA calculation, including those that could enable insurers to include in the calculation of QPAs contracted rates for services that providers have not provided, as well as allowing self-insured group health plans to use rates from all plans administered by a third-party administrator in calculating the QPA.  

According to Becker’s Hospital Review, Judge Jeremy Kernolde struck down TMA’s challenge regarding disclosure requirements, according to the lawsuit.  “While the court disagreed with TMA regarding disclosure requirements in the rules, we remain pleased with the overall outcome,” TMA President Rick Snyder, MD said in an August 25 statement.

The judge’s latest ruling was the second time he sided with the TMA in August. On Aug. 3, he ruled that the departments did not follow notice and comment requirements before raising administrative fee rates by a seven-fold factor. In addition, the court invalidated certain rules that narrowed the batching of claims for arbitration.  Following that decision, HHS said it was temporarily suspending the independent dispute resolution (IDR) process.

T for Texas

This latest action marks the fourth filing in federal court by the TMA in its battle against the departments’ NSA regulations. Its string of legal wins is remarkable. What is even more remarkable is that we only seem to hear about this one local group that is making an ongoing difference as it concerns national policy.  Where are the medical associations of other states or the national specialty societies?

It is quite interesting to see how one judge in one district of one state can cause a significant segment of the federal government to ditch major policy directives to which it has devoted significant time and resources in developing. Score another one for the local underdogs.

Next Steps

As a result of this latest legal victory, the Centers for Medicare and Medicaid Services (CMS)—an agency within HHS—announced on August 25 that the IDR process will be suspended, in response to the district court ruling. The suspension will remain in place until such time as the departments are able to develop and publish new rules that comport with the court’s latest decision.   According to a notice on the CMS website, dated August 25:

As a result of the TMA III decision, effective August 25, 2023, the Departments have temporarily suspended all Federal IDR process operations in order to make changes necessary to comply with the court’s opinion and order. Disputing parties should continue to engage in open negotiation.

That last sentence is important to notice as negotiations—without a federally approved arbiter—is the only way disputing parties can proceed until new regulations are in place.

There is no other update or timeline at this point relative to a final and legally approved set of NSA regulations. We don’t even know if this district court judge’s rulings will be affirmed by the U.S. District Court of Appeals (Fifth Circuit, New Orleans). So, once again, out-of-network providers in participating hospitals find themselves in a holding pattern, waiting to see if there will be a safe place to land.

With best wishes,

Chris Martin
Senior Vice President—BPO

from
https://www.coronishealth.com/blog/on-a-roll-another-victory-for-the-tma/

Transparency Matters: Enhancing RCM Processes in Your Laboratory

Revenue cycle management (RCM) is a crucial aspect of any laboratory’s operations, as it affects financial performance and patient satisfaction. However, many labs struggle with inefficient, outdated, or fragmented laboratory billing processes that lead to errors, delays, and lost revenue. Transparency ensures RCM in lab billing uses best practices and takes advantage of upgraded technology to create a high level of quality and efficiency.

Understanding the Impact of Transparent RCM Processes on Laboratory Operations

Healthcare is a competitive and complex environment, so optimizing laboratory billing services creates a more efficient revenue cycle overall, with financial sustainability and operational productivity. One key factor that can make or break a laboratory’s RCM performance is transparency. Transparency allows a laboratory to track, monitor, and communicate the status and outcomes of laboratory billing, coding, collections, and denials. Transparency identifies and addresses potential issues with RCM, improves workflows, enhances customer service, and increases accountability. A high level of transparency for a laboratory organization can also positively impact quality, compliance, productivity, and profitability.

Benefits of Transparency in Laboratory Billing and Reimbursement

One of the challenges that laboratories face is ensuring that they receive fair and timely payment for their services. Lack of clarity and consistency in the billing and reimbursement policies of third-party payers, government agencies, and patients can complicate this process. Transparency in lab billing and reimbursement can help to address this challenge by providing clear and accurate information to avoid confusion or frustration. With transparency, all parties involved in the lab billing process benefit when clarity is a top priority:

• Publish the cost and value of tests, including routine, diagnostic, or elective.

• Explain potential out-of-pocket costs for tests not covered by insurance.

• Provide (in writing) copies of patient rights and responsibilities. 

Additional benefits include a drop in error rates with the laboratory billing process, fewer disputes between patients and the laboratory, a low incidence of fraud, and improved customer satisfaction and trust.

The Role of Transparency in Improving Financial Performance and Operational Efficiency

Transparency enhances the financial performance and operational efficiency of any organization. Open communication, honesty, and accountability for decisions and actions positively affect stakeholders – patients, employees, investors, suppliers, and regulators. This level of transparency has the potential to improve financial performance and operational efficiency through: 

• Reducing costs, risks, and errors through best practices with updated laboratory billing systems

• Enhancing workflows and improving communication

• Learning, innovation, collaboration

• Improving processes and sharing ideas

A lack of transparency may damage trust, loyalty, and engagement among stakeholders, which can lead to a decrease in patient satisfaction, employee retention, vendor collaboration, and regulatory compliance. Ultimately, financial visibility is a key factor in a laboratory’s success. Transparency ensures that a laboratory is sustainable and manages finances responsibly by focusing on key performance indicators (KPIs) such as price per transaction, overall revenue, and customer satisfaction scores. 

Establishing Clear Policies and Guidelines for Lab RCM

Lab RCM is the process of ensuring that a laboratory gets paid for the services it provides. It involves billing, coding, collecting, and reconciling payments from patients, insurance companies, and other payers. Lab RCM must adhere to clear policies and guidelines for lab RCM to align with business goals and comply with industry standards and must follow current HIPAA guidelines and published ICD-10 coding regulations. 

Benefits of well-defined lab RCM policies and guidelines:

• Optimizes cash flow and reduces accounts receivable

• Reduces administrative costs

• Enhances customer service and satisfaction by providing accurate and timely billing and payment information

• Minimizes risk of errors, denials, audits, and penalties

Consider the following when developing lab RCM policies and guidelines:

• Assess current performance and identify areas for improvement

• Define objectives and KPIs

• Develop policies and guidelines based on best practices and industry benchmarks

• Implement policies and guidelines across the organization and provide appropriate training for employees

• Monitor performance and outcomes regularly, making adjustments as needed

By following these steps, laboratories can avoid compliance penalties through transparent and ethical practices with a robust policy framework. 

Leveraging Electronic Health Records (EHR) for Streamlined Billing and Documentation Processes

Electronic health records (EHR) are digital versions of patients’ medical histories, diagnoses, treatments, medications, laboratory and imaging results, and other health-related information. The EHR can improve the quality and efficiency of a laboratory’s services by streamlining RCM in lab billing and documentation processes. Here are some of the benefits of using EHR for these purposes:

• Reduces errors and duplication in billing and documentation with automatic capture of relevant laboratory results

• Facilitates communication and coordination between healthcare providers and authorized stakeholders through access and sharing of updated, accurate information in real-time

• Improves compliance and security, ensuring billing and documentation practices follow the latest regulations and standards by protecting sensitive data from unauthorized access or misuse

Using the electronic health record for lab billing and documentation can help laboratories save time, money, and resources while delivering better care and outcomes for their patients. 

Coronis Health – Your Clear Answer for Transparency in Laboratory RCM

Streamlining the billing process in any healthcare organization is critical to maintain a high level of financial performance, operational efficiency, and patient satisfaction. Laboratories must adhere to strict guidelines to ensure that they are compliant with procedures and documentation, with transparency being a key factor for a laboratory’s success. With a team of laboratory professionals and leaders, proprietary technology, and strict regulatory compliance, Coronis Health Laboratory & Pathology is dedicated to providing the best in service for laboratory billing and RCM. Establish clarity and a step towards transparency to boost your revenue. Contact Coronis Health today to find out how to make the most of your laboratory RCM. 

from
https://www.coronishealth.com/blog/transparency-matters-enhancing-rcm-processes-in-your-laboratory/

Understanding the Effects of Regulatory Changes on Laboratory Revenue Cycle Management

In the laboratory industry, compliance is a critical component of comprehensive and efficient revenue cycle management (RCM). With the ever-changing rules and regulations, a diligent laboratory RCM should establish a stringent compliance plan to prevent loss of income due to heavy fines and legal fees.

Impact of Regulatory Changes on Lab Billing and Coding

Lab billing and coding compliance focuses on monitoring and executing the appropriate clinical documentation of patient services. Compliance with regulatory changes ensures the billing and coding process upholds all applicable state and federal laws, regulations, and policies.

Failure to bill and code accurately may result in denied and rejected claims or strict penalties.

Leveraging Technology for Efficient Laboratory Revenue Cycle Management

Manual billing systems are no longer adequate to manage the complexities and demands of today’s laboratory business. Advanced laboratory RCM software tools, like our own RCM Clarity and Ai4AR, automate and streamline workflows while providing decision support and sophisticated information databases. Technology tools can instantly flag problems and identify missing or incorrect data. 

Technology enables the RCM process to achieve a more agile system that is updated in real-time, optimizes the billing process, and ensures compliance for timely reimbursement.

Strategies for Adapting to Regulatory Changes

Compliance requires continuous adaptation, education, and dedication to maintain the highest standards of collections, processing, and patient care. Many strategies can help laboratories adapt to regulatory changes, including:

• Stay abreast of healthcare compliance regulatory changes – remain informed of changes in laws and guidelines. Establish a system by hiring a dedicated team and using technology to monitor updates from key regulatory bodies, reviewing industry publications, pursuing continued education, and attending conferences to stay up to date with trends and best practices in compliance.
• Conduct a compliance analysis – assess your lab’s current practices, identify non-compliance areas, and evaluate associated risks. Performing a gap analysis provides valuable insights into facets of your system that require improvement, helping you create policies and procedures that guide your laboratory’s compliance efforts.

• Ensure data security and protect patient information – store patient information securely in electronic formats and implement the appropriate access controls, encryption, and storage systems.
• Maintain an efficient documentation system – use software and other technology tools to collect and store data for accurate documentation. Provide ongoing education to billing and coding staff and establish systems that prevent and detect potential fraud or abuse. Constantly review your documentation system to ensure it aligns with regulatory standards. 
• Foster a culture of compliance – build and promote a work environment that upholds integrity, ethics, and compliance. Establish transparency and encourage communication regarding compliance issues while providing adequate training tools, resources, and ongoing training to support staff.

Benefits of Proactive Compliance with Regulatory Changes

Regulatory compliance strategies help laboratories meet specific goals, remain competitive, and increase revenue. Other benefits of being proactive with compliance include:

• Improves workflows and business efficiency – following regulatory standards proactively boosts efficiency by creating streamlined workflows that enhance accuracy in laboratory billing and coding and finding strategies for data entry, organization, transmission, and storage. 
• Protects your business – maintaining compliance helps your laboratory build a credible reputation for peers and patients. Fines, penalties, and other legal issues may harm your reputation and impact your business. Compliance eliminates these risks.
• Increases your profitability – non-compliance can lead to fines and lawsuits, which are costly. Your laboratory might be unable to handle the payments on top of your typical operational costs, resulting in financial strain. Regulatory compliance may increase profitability by avoiding those hefty fines, improving your reputation, and expanding your base.

Utilizing Data Analytics for Improved Lab Revenue Cycle Management Performance

Laboratory RCM solutions include data analytics to identify trends and patterns in financial data. By analyzing data, you gain key insights into optimizing your revenue streams. For example, data analytics can help identify which services are most profitable. This allows you to focus on these areas while improving other services to maximize revenue. 

Data analytics can also help you identify and improve inefficiencies in your billing and payment processes. By analyzing data on denied claims, you can identify common reasons for denied claims and develop strategies to prevent them in the future. This reduces the number of denied claims, optimizes revenue cycle management overall, and boosts your revenue.

Collaborating with Industry Experts and Regulatory Bodies for Effective Compliance

When you partner with industry experts, you have direct access to knowledge, training, and experience that strengthen your organization. Working with experts means having a team who know healthcare compliance inside and out, are aware of trends, and are up to date on changing regulations. 

Collaborating with these experts and taking advantage of technology-driven laboratory RCM services are excellent ways to save time, resources, and money while improving the overall efficiency of your compliance processes. 

Coronis Health Laboratory & Pathology has a team of former laboratory leaders and RCM experts who have the experience and expertise to maintain compliance, navigate regulatory changes, and uncover hidden revenue streams for your lab. Our goal is to improve operational efficiency, reduce costs, and increase revenue for your lab. We leverage industry-leading technology and high-touch relationships that allow you to remain compliant while you focus on maintaining exceptional care with the best possible financial results.

If you’d like to learn more about how outsourcing laboratory billing can maximize reimbursements while helping you remain compliant, contact Coronis Health to request your complimentary financial checkup today.

from
https://www.coronishealth.com/blog/understanding-the-effects-of-regulatory-changes-on-laboratory-revenue-cycle-management/

Regulatory Compliance in Hospital Revenue Cycle Management

Regulatory compliance refers to a healthcare organization’s extensive efforts to ensure they have the appropriate measures and hospital billing processes that enable them to meet all legal and professional obligations. 

Maintaining regulatory compliance while managing hospital staff, caring for patients, and ensuring the highest standards of medical treatment is a complex and demanding endeavor that requires meticulous attention to detail, comprehensive training, and effective communication across all levels.

Identifying Key Regulations Impacting Revenue Cycle Management

Revenue cycle management is an essential aspect of healthcare operations that is subject to various legal and regulatory compliance requirements. These are the key regulations all healthcare organizations are likely to be subject to:

• HIPAA – the Health Insurance Portability and Accountability Act of 1996 is a federal law that protects the privacy of certain health information. The HIPAA Privacy Rule sets the standards for using and disclosing individuals’ health information (known as protected health information, or PHI), while the Security Rule establishes security standards that protect certain health information that is held or transferred electronically.
• The HITECH Act – the Health Information Technology for Economic and Clinical Health Act of 2009 ensures healthcare providers use Electronic Health Records (EHR) and support healthcare information technology. The Act sets the standard for information security, provides financial security and penalties for healthcare providers and associated businesses, and encourages them to proactively protect patient information.

• EMTALA – the Emergency Medical Treatment and Labor Act of 1986 ensures greater public access to emergency services regardless of their insurance status and ability to pay.
• AKBS and Stark Laws – the Anti-Kickback Statute prohibits the abuse of the healthcare system for financial gain. The AKBS ensures that no healthcare professional or organization offers or receives any reward or financial incentive for an award or the referral of patients. 

The Stark Law is a set of fraud and abuse laws that prohibit physicians from referring patients to other medical entities from which the referring physician or their family could receive financial gain.

• PSQIA – the Patient Safety and Quality Improvement Act of 2005 is a voluntary reporting system that enhances the data available to resolve patient safety and health issues and protects healthcare workers who report unsafe conditions at their organization. The Act allows individuals to report medical errors while maintaining patient confidentiality.

Compliance Challenges in Hospital Revenue Cycle Management

To remain compliant, hospitals must address the following challenges:

Cybersecurity threats

Hospitals store confidential patient data that is worth a lot of money to hackers who sell it, making the healthcare industry a vulnerable target. It is crucial to update security systems and strengthen digital infrastructures at all levels – from hospital billing and coding to data entry and other components of the revenue cycle. Taking this for granted can put patient safety at risk and damage an organization’s integrity.

The rise of telemedicine

The pandemic has highlighted the relevance and usefulness of telemedicine in delivering patient care, but regulating telehealth remains a controversial issue because it is relatively new.

Still, hospitals must prepare to adopt telehealth services and, in turn, prioritize cybersecurity to protect sensitive patient information.

Hiring ethical and compliant professionals

The first step to maintaining compliance is hiring the right people. Organizations must strengthen their screening process to find the most ethical and compliant individuals to join their team. Having knowledgeable and experienced members will make it easier to keep up with the healthcare industry’s ever-changing regulations.

Promoting compliance may also mean placing the responsibility in the hands of trusted and experienced professionals who know best.

At Coronis Health, we never underestimate the importance of compliance in revenue cycle management. Our collaboration with the best of the best in revenue cycle management ensures we understand your facility’s competitive landscape while keeping abreast of the latest regulations.

If you’d like to learn more about how you can remain compliant and keep your hospital billing optimized, contact Coronis Health to see how we can improve your revenue today.

from
https://www.coronishealth.com/blog/regulatory-compliance-in-hospital-revenue-cycle-management/

Leveraging BPO to Navigate Regulatory Compliance Challenges in Healthcare

The healthcare industry is facing increasing pressure to comply with various regulations and standards, such as HIPAA and Health Information Technology for Economic and Clinical Health  (HITECH). Patients are concerned about their privacy and protected data, while providers strive to protect a patient’s information and deliver quality care. Regulations are in place to protect the privacy and security of patients’ data, but they also pose significant challenges for healthcare providers and organizations. How can we ensure compliance while maintaining efficiency and quality of service? One of the trending practices in healthcare is partnering with a company for business process outsourcing (BPO). 

The Role of BPO in the Healthcare Industry

BPO, or business process outsourcing, involves outsourcing non-core functions of a healthcare organization to reduce costs, improve efficiency, and enhance the patient experience. Some of the common functions that healthcare providers outsource to BPO companies include: 

• Scheduling
• Eligibility verification and pre-authorization
• Data entry
• Insurance Billing and F/U
• Denials Management
• Cash acceleration
• Edit resolution
• Low balance and credit balance claims
• Legacy A/R wind down
• Payment posting

Outsourced tasks allow healthcare providers to focus on providing quality care to patients, improving clinical outcomes, and innovating new solutions. BPO can also help organizations comply with regulatory standards, maintain data security, and access skilled talent and advanced technology.

How BPO Can Help Address Compliance Challenges

BPO compliance is a key concern for any healthcare organization. Compliance challenges can arise from changing laws, complex regulations, and increasing patient expectations. A lack of compliance can result in fines, lawsuits, reputational damage, and loss of trust.

Choosing a reputable agency for healthcare BPO can help to mitigate these challenges by taking over some of these tasks:

• Quality assurance, monitoring of data security and privacy

• Risk management, mitigation, audit support, and documentation

• Required updates and training

Healthcare BPO can help organizations adapt to changing compliance requirements and stay ahead of the competition, keeping the provider’s focus on patient care. Compliance in the BPO industry facilitates higher levels of quality care because these tasks are eliminated from the workflows of a healthcare organization. 

Future Trends: BPO and Healthcare Regulatory Compliance

The healthcare industry is evolving and facing new challenges, especially in the areas of regulatory compliance and data security. Many organizations are outsourcing some of their functions to stay ahead of the changes, allowing them to keep their focus on patient care. Choosing a BPO partner involves entrusting sensitive information and critical processes to a third party, and while the trend of outsourcing is not new, there are important points to remember:

• BPOs must adhere to strict regulations related to the Affordable Care Act, HIPAA, General Data Protection Regulation (GDPR), and Payment Card Industry Data Security Standard (PIC-DSS), and maintain certifications and quality assurance processes.

• Enforcement of policies and safeguards for protection of confidentiality, integrity, and availability of healthcare data is critical. This includes management of data breaches, incidents, and disaster recovery scenarios.

• Share expectations, deliverables, metrics, and penalties for non-compliance in service level agreements (SLA), and the ability to audit performance and compliance in BPO.

The Impact of AI and Automation on Healthcare BPO

Artificial intelligence (AI) and automation can help healthcare BPO providers with streamlining and optimization of processes and accuracy, offering more value-added services, such as data analytics, fraud detection, and patient engagement.

AI and automation are emerging technologies that can transform the healthcare BPO industry by focusing on intelligent data processing, analysis and decision making, while automation can streamline repetitive and manual tasks. They can enhance quality, accuracy, and speed of healthcare BPO services, as well as reduce human errors and operational costs.

• AI automates medical coding and billing processes, reducing errors and improving BPO compliance. It analyzes large volumes of patient data, generating insights for diagnosis, treatment, and prevention. “Chatbots” and virtual assistants improve customer service and patient engagement.

• Automation manages appointment scheduling, claims processing, document management, and improves data security and privacy by encrypting and anonymizing sensitive information.

AI and automation create new opportunities and challenges for healthcare BPO providers, but they require an investment in new skills, technologies, and infrastructure. Adapting to changing market demands and leveraging the benefits of AI and automation ensures an organization remains competitive and relevant in the industry.

Anticipating Future Regulatory Challenges in Healthcare

Healthcare evolves through technology, new treatments, and changing business models, so it’s necessary for organizations to anticipate and adapt to the changing rules and expectations of regulators. Preparing for the future will require healthcare organizations and BPO vendors to focus on the following:

• Data privacy and security – critical when considering the use of digital health tools, such as telemedicine, wearable devices, AI, and blockchain. 

• Quality and safety standards – must adhere to higher quality and safety standards to ensure efficacy, reliability and usability. 

• Ethical and social implications – may challenge existing norms, values, and laws, such as gene editing, stem cell therapy, organ transplantation, and human augmentation. 

Keep the future in sight when considering a healthcare BPO. As fast as technology advances – the need to keep up with the changes is critical to the success of the transition from in-house processes to outsourced services. 

Choosing the Right BPO Partner

A good BPO partner can help you reduce costs, improve efficiency, and enhance customer satisfaction. However, not all BPO providers are created equal, and you need to do your homework before signing a contract. Here are some tips to help you find the best BPO partner for your needs:

• Define your goals and expectations clearly – determine your main objectives of outsourcing.

• Do your research and compare different options – look for BPO providers that have experience and expertise in your industry and domain.

• Evaluate their capabilities and infrastructure – make sure they are equipped to manage your volume and complexity of work.

• Negotiate the terms and conditions of the contract – make sure you understand the scope, duration, and cost of the project.

Choosing the right BPO partner can make a big difference in your business performance and growth. At Coronis Health, you can trust that you’re partnering with experts who understand the challenges you face, and how they can take the burden from your organization. Coronis is the next step in giving you the opportunity to manage what matters the most. Contact us today to find out if healthcare BPO is right for your organization.

from
https://www.coronishealth.com/blog/leveraging-bpo-to-navigate-regulatory-compliance-challenges-in-healthcare/

The Impact of Outsourcing Revenue Cycle Management on Hospital Operations

Outsourcing revenue cycle management (RCM) is a common practice among hospitals that want to improve financial performance and efficiency. Hospital revenue cycle management involves the processes from billing to payment collection. By outsourcing these tasks to a third-party vendor, hospitals can reduce administrative costs, increase cash flow, and focus on the mission and vision. 

Benefits of Outsourcing Revenue Cycle Management for Hospitals

Many hospitals struggle with RCM due to workflow inefficiencies, errors, staff shortages, and changing regulations. Outsourcing hospital RCM services to an experienced leader in the industry can help to overcome challenges and improve financial performance. Streamlining RCM helps hospitals strengthen the relationship and trust between the hospital and the patient by providing a better patient experience. 

Increased Revenue and Efficiency

Outsourcing can help streamline and simplify billing and coding processes, reduce errors and denials, and ensure timely reimbursements. Experienced vendors leverage advanced technology, data analytics, and best practices to optimize the RCM workflow and increase cash flow. Fewer errors with billing and coding, decreased days in accounts receivable, and a significant decrease in denials are a considerable benefit for outsourcing hospital RCM. 

• RCM in a hospital can enhance efficiency, allowing staff to focus on patient care and core activities. 

• The outsourced company manages hiring, training, and supervision of RCM staff, as well as oversight on compliance and regulatory issues. 

• Registration, insurance verification, eligibility checks, and patient collections are managed by outsourced RCM staff. 

Access to Expertise and Advanced Technology

Leading RCM companies have access to the latest technology and innovation – artificial intelligence, machine learning, automation, and cloud computing. Vendors must integrate seamlessly with a hospital’s existing systems and platforms – the electronic health record (EHR) system, practice management and billing software, and other ancillary support systems for the hospital’s RCM. 

The Direct Impact of Outsourcing on Hospital Operations

Effective hospital revenue cycle management solutions can improve financial performance and operational efficiency. The decision to consider RCM tasks is a step in the right direction. RCM in a hospital is a complex and time-consuming process that requires specialized skills and technology that only an experienced vendor can offer. Outsourcing RCM to a third-party expert offers several key benefits.

Streamlined Administrative Functions

Outsourcing RCM can reduce the burden of billing, coding, and collecting payments, allowing hospital staff to focus on the mission and vision of the hospital. Accuracy and efficiency of the claims process improves, resulting in fewer denials and faster reimbursements. Other benefits include:

• Quality improvement: Outsourcing enhances the quality of services or products by leveraging the expertise and experience of specialized providers.

• Flexibility and scalability: Outsourcing allows hospitals to adapt to changing demands and needs, and accessing new technologies and innovations.

Hospitals may enjoy a boost in productivity with outsourced hospital revenue cycle management. Experienced RCM providers develop accurate and timely reports, real-time dashboards, and insights on a hospital’s financial performance. These vendors offer guidance and direction on how to improve the RCM process and address any issues or gaps.

Reduction in Operational Costs

Using an outside service for hospital RCM can transform hospital operations, enhancing efficiency, compliance, and generating revenue. Reducing operational costs offers several advantages for a hospital’s bottom line, including: 

• Cost savings: Hospitals can reduce labor costs, overheads, and capital expenditures such as technology, software, and hardware. 

• The cost of training employees for revenue cycle management is also eliminated. 

Outsourcing hospital RCM may be a smart move for hospitals that want to improve financial performance and operational efficiency. Partnering with a reliable and experienced vendor can provide cost savings, compliance, and revenue growth. 

Potential Challenges in Outsourcing Revenue Cycle Management

Partnering with an experienced RCM company that prioritizes your best interests can help minimize outsourcing challenges such as:

• Delays in communication: Communication gaps may hinder productivity, especially if different time zones or systems are a factor. These factors may affect quality and timeliness of hospital RCM services, such as billing, coding, and collections.

• Principal-agent conflicts: Hospitals and vendors may have different goals and incentives – a vendor may prioritize maximizing their profit over optimizing the provider’s revenue cycle performance. This can result in a conflict of interest and damage the relationship between the hospital and the vendor.

Data Privacy and Security Concerns

Hospitals must ensure that their RCM vendors comply with the Health Insurance Portability and Accountability Act (HIPAA) and other relevant regulations, and that they have adequate safeguards to protect the confidentiality, integrity, and availability of patient data. Hospitals should also monitor and audit their RCM vendors regularly, and have contingency plans in case of data breaches or other incidents.

Providing access to sensitive patient and financial data to the vendor and their subcontractors may pose security risks, privacy breaches, and compliance issues. Do your research to ensure that the company you choose to manage your revenue cycle has a trustworthy reputation and can confidently protect your patient data. 

Outsource Hospital Revenue Cycle Management with Coronis Health

Coronis Health is a pioneer in hospital RCM. With decades of experience and a team of industry leaders, we can work with your hospital to reduce costs, improve cash flow, and enhance patient satisfaction. We can help manage your revenue cycle so you can focus on patient care, strategic initiatives, and the overall performance of your hospital. To learn more, contact Coronis Health for a 1:1 Executive Consultation to assess your current situation and identify areas of improvement. Don’t miss this opportunity to optimize your revenue cycle and achieve your financial goals. 

from
https://www.coronishealth.com/blog/the-impact-of-outsourcing-revenue-cycle-management-on-hospital-operations/