Affected by the Labor Shortage? Coronis Can Help

Health care facilities are under constant pressure to reduce costs and improve productivity—to do more with less. The increased demands and staff shortages brought about by the COVID-19 pandemic have further exacerbated an already challenging situation. 

In a tight health care labor market, your ability to maintain continuity of patient care with manageable staffing levels may be compromised. Coronis can help. We can evaluate your facility’s requirements and bring in the cost-effective talent you need in an efficient and scalable way.

What the Numbers Show

Hospitals are at the center of a national staffing shortage due to a combination of high COVID-19 patient volume and staff departures during the pandemic. Still, there is little national data available to quantify the shortages’ impact on patient care.

The first indication came in the form of a CDC report indicating that healthcare-associated infections would increase significantly in 2020 following years of steady decline. The researchers attributed the increase to pandemic-related challenges, such as staffing shortages and high patient volumes, which made it difficult for hospitals to follow standard infection control practices.

For example, the Joint Commission received 569 reports of sentinel events in the first six months of 2021, up from 437 in the first six months of 2020. However, meaningful conclusions about the events’ frequency and long-term trends cannot be drawn from the dataset. The Joint Commission estimates that fewer than 2% of all sentinel events are reported to the organization.

The Safety Impact of Labor Shortages

Nurses, physicians, and other health care professionals are leaders in patient safety. They’re the people who interact with patients daily—advocating for patient safety and making decisions and taking actions to promote safety.

There’s no doubt that workforce shortages in healthcare facilities can negatively impact patient safety. Research has found that labor shortages in hospitals exist across a broad range of occupations and specialties—from registered nurses and licensed practical nurses to respiratory therapists and paramedics. 

Improving the Revenue Cycle

Many healthcare organizations have adopted lean principles to lower costs, decrease waste, and improve the quality of care.

Tightening up revenue cycle management (RCM) is a crucial part of many lean initiatives. Improving the revenue cycle is not just a cost-cutting measure; it has the added benefit of increasing revenue to secure additional staff and resources. 

Revenue cycle management allows health care organizations to concentrate on improving efficiency so they can spend more money on attracting and retaining top talent. 

When you outsource routine RCM functions such as registration, billing, collections, denial management, coding, and insurance eligibility verification to Coronis, you can focus on hiring  only medical and clinical staff, rather than administrative staff as well. With fewer employees to manage, you can focus on your facility’s clinical needs rather than on financial pressures and performance, which your RCM partner can handle.

Outsourcing May Be Your Best Friend

No matter your line of work, competition is tough. This is especially true in the healthcare field. The system is already stressed, and with an aging population and a limited number of medical practitioners, the job market is becoming increasingly tight with higher demand and fewer resources.

This means that you may need to think outside the box regarding hiring practices. A viable alternative is to outsource certain functions if you feel that you can’t keep up with the growing workload or can’t keep up with the quality of care that patients deserve from your facility.

Outsourcing has become increasingly common in the healthcare industry. According to the Society for Human Resource Management (SHRM), most organizations decide to outsource work when they need help managing temporary or long-term workforce needs. 

This can be particularly beneficial during busy periods or if a company is experiencing staffing problems—such as those currently plaguing healthcare organizations everywhere. It also allows facilities to focus on patient care delivery rather than on administrative functions. 

By providing a range of services that can help alleviate stress for employees and increase overall productivity at your facility, outsourcing can address specific areas of concern. 

These services may include:

• Billing services  
• Coding 
• Collections and denial management
• Revenue cycle management
• System integration

Outsourcing these administrative functions may be a valuable strategy, enabling your facility to focus on its core operations and maintain patient safety in this tight labor market.

Partner With Coronis Health To Help Maintain Your Facility’s Quality of Care

Coronis is committed to supporting the frontline caregivers who work hard every day, every shift, to keep patients safe. 

Healthy finances lay the foundation for quality care. Our goal is to maximize your profits and reduce your administrative costs so you can continue providing quality care for your patients.

To receive your free financial checkup or to learn more about how we can help your facility in this demanding environment during these stressful times, contact Coronis Health today.

from
https://www.coronishealth.com/blog/affected-by-the-labor-shortage-coronis-can-help/

7 Signs You Need to Outsource

Medical billing is a complex process that requires the focus of skilled, certified billers and coders who are trained in the procedures that facilitate a healthy revenue cycle and prompt reimbursement for a healthcare facility. If you are struggling with timely filing, delays in receiving reimbursement, or staff burnout, you may need to consider outsourcing your medical billing. Here are the signs that may take you one step closer to outsourcing your medical billing and revenue cycle management. 

1. Strains on Your Administrative Staff

Healthcare is a dynamic, challenging industry, and requires a special team of highly trained clinicians and administrative personnel to accomplish many tasks related to patient care. Burnout is not uncommon in healthcare, and if your staff feel overworked or strained to complete their work, you will see a higher rate of turnover and dissatisfaction in your organization. Medical billing is not immune to turnover, as a facility’s focus on revenue-centered results places pressure on billers and coders to push high volumes of claims in shorter time frames, with a high level of accuracy. 

If you are seeing inconsistencies in your revenue cycle, such as issues with your accounts receivable (A/R), timely filing, or an increase in denials, you may have staff who are struggling to keep up with the demands of the work, and may choose to leave your organization. Hiring and training new staff is a costly affair, as you need to find the right fit – someone who is certified and highly trained, and can manage your expectations. Where revenue is concerned, you must set your expectations high, and the demands of your medical billing team will subsequently increase. Keeping a tight-knit billing staff in a facility is tough, so if you are feeling the strain of losing employees due to burnout, it may be time to choose an outsourced medical billing company that focuses solely on medical billing and coding – and nothing else. 

2. Delayed Payments

Healthcare facilities need prompt payment from medical claims to operate effectively, but if claims are not paid in a timely manner, the denied claim workload for your medical billing team increases and creates additional strain. Denied claims are the number one reason for a delay in payments, and could be related to several factors such as overworked staff – which can result in a high rate of billing or coding errors, or having to constantly train new clinicians or staff. 

The decision to outsource medical billing is a step in the right direction; you are choosing to have a group of highly trained professionals to take over your claims review process. By placing your trust in a medical billing company, you are facilitating success as your new medical billing company will ensure a high rate – as much as 99% – of clean claims, which significantly decreases the number of delayed payments. 

3. Decline in Clean Claims Percentage

Clean claims are simple to understand – they are a simple ratio – the average number of claims paid after the first submission. These claims are not stained by the delay of denials or long wait times in A/R, and the percentage should be 95% or higher. If your facility has a clean claims rate lower than 85%, your revenue cycle management strategy is lacking. Imagine 1,000 claims submitted, with only 850 paid after the first submission. This means 150 claims need to be reworked, rebilled, recoded, and resubmitted, which delays payment and could increase the number of days in your A/R as well. 

The percentage of your clean claims rate is a byproduct of the work your staff is completing, so the lower your percentage, the more time your staff is spending on reviewing denials, communicating with payers, and fixing errors before submitting a claim for the second time. 

Denials tell a compelling story about your revenue cycle management strategy. Your clean claims percentage could be telling you to re-write your strategy and outsource your medical billing. 

4. Diminished Revenue

Healthcare facilities have a tough decision regarding medical billing when opening the doors for the first time, as there is little revenue to cover the cost of adding a vendor. If your facility is well established and has a good stream of revenue, it might be time to consider outsourcing your medical billing. There comes a time when the billing process outgrows itself and eventually costs more to keep it in-house. 

The costs of outsourcing your medical billing could possibly equal the costs of keeping it in-house, but the better option is to move forward with outsourcing. An outside revenue cycle management company helps you convert the high, fixed employee costs to a variable expense that can be connected to revenue. Remember, if your revenue diminishes, you still have to pay your staff. Those expenses are fixed and cannot adjust with a loss in revenue.

Compare your revenue with the industry median; if you fall below the industry average, outsourcing could be the key to optimizing your revenue. A robust revenue cycle management strategy is an essential component of operational success for your facility, and ultimately reduces your operating costs.  

5. Struggles Keeping Up with Regulation Changes

The government and other organizations, such as the Centers for Medicare and Medicaid (CMS) dictate the rules and regulations for medical billing. New protocols are constantly introduced by CMS and other third party payers, so it’s critical to ensure that medical billers and coders are consistently updated on changes that affect the billing process. Predicting these changes is not easy, but the changes are inevitable and expected. 

Certified medical billers and coders in an outsourced company focus only on billing and coding, and are constantly updated on new information as it is disseminated by insurance payers and CMS. The information they receive ensures they remain compliant, are up to date on every regulation, and submit accurate, clean claims for your facility. 

6. More Time Spent in A/R

Your facility must understand the many reasons a claim is rejected, but closer attention is required for the number of days a payment is sitting in accounts receivable (A/R), where money due from a claim waits. Medical billers are required to submit claims on time, so a facility should expect that reimbursement would be distributed on time. It’s important to review A/R on a monthly basis to flag payments that are older than 30 days, but the larger your facility, the more difficult it becomes for your in-house medical billing staff to focus on the time spent in A/R. 

An outsourced medical billing company has teams that focus only on denials or A/R. Since they are not tasked with other facility responsibilities, the ability to track and manage A/R becomes less arduous. 

7. Lower Quality of Patient Care

When your staff are overworked and stressed, they will not deliver excellent, quality care to patients. Managing medical billing is complex enough, so adding to the plate with extra tasks such as scheduling appointments and interacting with patients adds to a biller’s workload, and reduces their ability to function at an optimal level. When this happens, a patient’s expectations are not met, quality care is absent, and patient satisfaction rates drop. 

Outsourcing medical billing takes the weight off your team. Let your staff focus on the main purpose of the facility – taking care of the patients, and let the outsourced company do what they know best – medical billing, coding, and managing your revenue cycle process.

Choosing Coronis Health for Your Billing Needs

Coronis Health combines years of expertise with a thirst for providing excellent customer service to ensure that your billing needs are addressed. We provide revenue cycle management services for laboratories and pathologists, behavioral health, hospitals and surgery centers, primary care and specialty physicians, FQHC and CHC services, anesthesia, and emergency medical services.

Additionally, Our team of certified billers and coders are dedicated to providing high quality services so you can focus on your patients. One of the best moves you can make for the revenue health of your facility is to outsource your medical billing or overall revenue cycle management process to Coronis Health. Contact us today for a financial checkup and find out why we are your solution to revenue cycle management. 

from
https://www.coronishealth.com/blog/7-signs-you-need-to-outsource/

Outsourcing Medical Billing: Benefits vs. Costs

Outsourcing medical billing may sound expensive, but the benefits can outweigh the costs. Let’s explore the real ROI on outsourcing medical billing – Coronis Health can provide tips to help you determine whether outsourcing is the right choice for your facility. 

5 Signs You Should Outsource Your Medical Billing

Medical billing is a critical component of your facility’s revenue cycle, as it ensures that you are earning the reimbursement from the submitted claims of the services you provide. If you are struggling with your accounts receivable, staffing, and an overall lower collection rate, you may need to consider outsourcing your medical billing. There are five significant signs that indicate a need to make the transition to outsourced medical billing.

Long Accounts Receivable

Accounts receivable (A/R) is money owed to your facility from an insurance payer; the key is to keep days in A/R less than 30 (ideally). The longer owed money sits in A/R, the longer your facility goes without receiving reimbursements. If your facility’s A/R is 45 days or more, this should be a reason to analyze the core reasons you are not collecting reimbursements or patient payments in a timely manner. 

Declining Revenue

Part of your revenue cycle is tied to your collection processes, and without a solid foundation of collecting on outstanding payments from insurance payers and patients, you will see a decline in your facility’s revenue. Coronis Health focuses on providing streamlined billing services for your facility to ensure that you experience an increase in revenue, rather than a decline in the lifeblood of your facility’s operations. 

Higher Operational Expenses

In-house medical billing is not just about reimbursement for services rendered – operational expenses are a critical component related to the cost of medical billing, which many facilities do not consider in the bigger picture of operations. The following factors contribute to a higher operational expense for a facility that uses in-house medical billing:

• Finding and hiring highly trained and certified billers and coders
• Paying hourly wages, which includes the employer share of taxes and employee benefits
• Licensing for software (depending on number of employees, you may be charged per license)
• Clearinghouse fees 
• Statement fees and postage, including the cost of printing
• Based on how many medical billers and/or coders you employ, a smaller billing department could be less productive and unable to handle the load of increased rejections and denials
• Decrease in collections and cash flow
• Increase in patient debt

These factors correlate with your facility’s ability to maintain a reasonable rate of operational expenses. When the costs of the above are factored into the cost savings of outsourcing your medical billing, you will discover that the increase in your net collections (your revenue) will surpass not only your previous operational expenses, but the fee you end up paying for your outsourcing. You end up making more in the long run. 

Lower Net Collection Rate

The net collection rate is the amount of money your facility collects on claims after excluding the adjustments applied by contractual agreements, however, denied claims factor into your net collection rate. An inexperienced medical biller, or a billing department with insufficient staff may write off denied claims instead of engaging in proper follow-up or resubmission of the claim. The rate at which this happens could decimate your facility’s revenue health. 

High Staff Turnover

Employee turnover relates to multiple factors, from job satisfaction to pay, but in medical billing, an organization may have a difficult time trying to find and keep certified medical billers and coders. This leaves billing departments short-staffed and pressured to keep up with mounting A/R and denial rates, correcting errors, and resubmitting claims.

The average length of employment for a medical biller is anywhere from 1 to 3 years, which means a higher rate of turnover for an organization. The cost of hiring and training has to be factored into the cost of operations, so a high rate of staff turnover is something to consider when determining if you will outsource your medical billing. 

Benefits of Outsourcing

One of the key benefits of outsourcing medical billing for your facility is the centralization and standardization of billing practices. Additionally, you will see a lower cost of operations, a decrease in billing mistakes, improved compliance, and above all else, happy patients. 

Lower Costs

Operational costs come with the territory of running a medical facility, but you want to keep them under control to ensure a healthy revenue stream. On average, most healthcare facilities can spend anywhere from 30 to 40 percent of their revenue on medical billing, but outsourcing this process significantly reduces operational costs. The money spent to train, recertify, and keep medical billers up to date on the latest regulations is an additional cost, and is eliminated when the billing process is outsourced. 

Fewer Mistakes

Billing errors can create a potentially large hit on your revenue. Errors include inefficient collection policies, incorrect coding, errors with patient registration and insurance verification, and lack of documentation with a claim. One mistake can result in a denied claim or delayed payment, and will ultimately result in continued mistakes with costly results. 

Medical billers specialize in many fields, from primary care to surgery, so it’s important to outsource with the right company that understands the intricacies of your facility. This ensures that you see fewer mistakes with billing, which means your net collections increase, your denials decrease, and your operational costs are more than manageable. 

Improved Compliance

Healthcare is a dynamic industry – regulations change to accommodate fluctuations with government requirements, insurance payers, and changes with technology and science. The Centers for Medicare and Medicaid (CMS) also implement strict guidelines for billing, so it’s important for a medical biller to be up to speed on changes that can affect the billing process for a facility. 

Certified medical billers and coders must learn and understand the regulations that govern how insurance payers reimburse, and how facilities must document to receive reimbursement. They are trained on how to apply coding that correlates correctly with clinical documentation, and are consistently updated on any changes that apply to coding or billing procedures. Outsourcing your medical billing ensures that you are working with a team that focuses 100% of their time on billing. You will see an improvement in compliance with billing regulations as your outsourced billing is following the guidelines set forth by the government and CMS. 

Happier Patients

Patient experience is an integral part of success in healthcare, as it signifies the quality, reputation and culture of the organization and its people. When patients are happy, there are multiple facets to that level of happiness, and it includes their perception of the billing process. A facility understands revenue cycle and everything it entails, but patients look at only what they can see – registration, insurance, what they have to pay up front, what they are billed, and their interactions with a billing department. When you keep your billing processes in-house, your support staff, which also includes your billers and coders, have responsibilities that extend to scheduling appointments, managing calls from patients, and other tasks that remove the focus from the purpose of their job – billing and coding. 

By outsourcing your facility’s medical billing, you are freeing up your staff to focus on creating the best experience for your patients. One of the most difficult aspects of keeping billing in-house is fielding the many phone calls related to patient bills, which sometimes involves more than just the billing department to resolve. Outsourcing medical billing gives your staff the ability to engage with patients without the stress of having to discuss a bill. With a better patient experience, you will see higher patient retention and satisfaction.

Outsourcing your billing services may seem like an expense your facility can’t afford, but in truth, it may be an investment your facility can’t live without. By outsourcing, you may find your revenue increases, your operations become more efficient, and your patients enjoy a higher level of care. 

Are you ready to take a closer look at outsourcing your medical billing? Let’s start a conversation. 

from
https://www.coronishealth.com/blog/outsourcing-medical-billing-benefits-vs-costs/

Complexity of RCM Leads Practices to Outsource

Your facility’s financial success is attributed to multiple factors, with revenue cycle management at the top of the list. From collecting payments at the front desk to handling your AR, managing the complexities of the revenue cycle should not be stressful or taxing on your staffing. Coronis Health provides the specialized solutions for outsourcing your billing and revenue cycle management needs so you can focus on the most important aspect of your business – the patients.

What is RCM?

Revenue cycle management, or RCM, is a full-circle process that culminates with your facility earning revenue from the services delivered to patients. The cycle starts with the simple task of registering a patient and verifying their eligibility and insurance, and ends with the final collection from the patient or insurance payer. The process may seem lengthy, as it involves multiple players, including the patient, facility, billers and coders, and the health insurance companies that reimburse a hospital or healthcare facility. Ultimately, the management of this process falls on the healthcare facility, so a full understanding of the cycle is critical for the success of an organization.

Why Is It So Complex?

Revenue cycle management is not as simple as a retail store collecting money for a sale, which happens instantaneously. Patients receive services before a billing department submits a claim, and if a claim is denied or part of the claim is not covered, the reimbursement process is delayed. Additionally, the changes with ICD-10 create challenges that demand accurate documentation and coding, so if a healthcare facility does not engage in effective billing practices, the rate of denials increase, and accounts receivable (or A/R, the amount of money an insurance company owes a healthcare facility) can soar to an unmanageable level. Increased denials make it difficult to collect earned reimbursement from insurance companies.

RCM Challenges

Revenue cycle management presents challenges that require a healthcare facility to focus on multiple factors to ensure the process is successful. The following challenges demand a savvy team of experienced professionals who know and understand the full circle of revenue cycle management:

• Prior authorizations are necessary for healthcare facilities to ensure that a patient receives care that an insurance company approves prior to the date of service. Providing care or performing a procedure without prior authorization could lead to claim denial, and ultimately place the responsibility of payment with the patient.
• Revenue integrity involves capturing accurate charges, which determine the amount of reimbursement a facility receives. Facilities with specialties may face more challenges as they focus on value-based care, bundle their charges, and perform procedures.
• Accurate coding is essential to ensure that patient encounters, procedures, laboratory and imaging services, and surgery claims capture codes correctly to prevent loss of reimbursement. Incorrect coding can result in a loss of revenue for a facility.
• Management of A/R is critical for a healthcare facility, as it determines how soon reimbursement is received after submitting a claim. Keeping A/R under 30 days needs a team of dedicated individuals who understand and implement effective strategies to lower denial rates and increase collection rates.
• Credentialing and proper enrollment with an insurance payer is required for reimbursement. Physicians or facilities who are not enrolled or not “in-network” with a plan could face negative revenue outcomes, which also affects patients who receive services.

Coronis Health moves past these challenges to create success and alleviate the stress of billing, coding, and the revenue cycle process.

Benefits of Robust RCM

Outsourcing revenue cycle management is a choice that many healthcare facilities are making to ensure they have certified professionals who engage in regulated, proven methods of obtaining prior authorizations, accurate charge capturing and coding, claim submission, denial and A/R management, and collection. A robust revenue cycle management ensures that all pieces of the process are touched with every patient encounter, with zero money left on the table. The effective utilization of a revenue cycle team creates the centralization a healthcare facility needs to meet the challenges the industry presents with enormous amounts of data, changes, and regulations. It also aims to keep a facility operating with its doors wide open to care for patients.

Coronis Offers RCM Services

Don’t think that outsourcing means you lost control – in fact, you are creating more control for your facility as you are creating opportunities to create process improvement in other departments that may have suffered productivity or revenue losses. Let Coronis Health do the heavy lifting with revenue cycle management. Coronis offers services that optimize your facility’s revenue while streamlining your processes:

• Eliminate your concern for staffing shortages
• Provide a dedicated team that addresses changes with payer reimbursements
• Work closely with facilities that change practice management/EHR systems
• Ensure coding compliance, auditing services
• Maximize patient collection
• Decrease A/R to ensure timely reimbursement payments are received
• Offer billing services, to include:
  • Laboratory & Pathology
  • Behavioral Health
  • Hospital and Surgery Center
  • Primary Care and Specialty Physicians
  • Federally Qualified Health Centers/Community Health Centers
  • Anesthesia
  • EMS

Choose Coronis Health for Your Outsourcing Needs

Choose the best – choose Coronis Health for your outsourcing needs. We offer superior medical billing and technology innovation, integrating our services with your needs. We combine 100+ years of experience to tailor solutions and offer more than just medical billing. We go beyond your expectations with the latest technology, forward-thinking, and robust business intelligence. We grow with your processes and provide you with the services that maximize your revenue cycle management. We understand your needs, build trust, and gain a firm perspective of your facility’s goals, mission, and vision. Trust us to create a revenue cycle management team focused on your success.

Interested to learn more? Request your free financial checkup and find out why Coronis Health is the optimal choice for your healthcare facility. 

from
https://www.coronishealth.com/blog/complexity-of-rcm-leads-practices-to-outsource/

Breaking Down the No Surprises Act

Overview:

Effective in 2022, the No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers. It also establishes an independent dispute resolution process for payment disputes between plans and providers, and provides new dispute resolution opportunities for uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate they get from the provider.  The Act is better understood by breaking it down into two parts.

• Part one is intended for emergency care, in-patient and facility providers (e.g. hospitals, facilities, etc).
  • If a patient has health coverage and receives emergency care; the act bans most common types of surprise bills.
• Part two is transparency of medical services and costs being provided.  Supplying patients with a Good Faith Estimate (GFE) of care.  This includes INN, OON and out-patient.
  • If a patient is self-pay,  uninsured or plans not to use their health coverage; the act states a GFE of the cost of care is to be provided before visit.

It is good to note that everyone’s understanding of the act is evolving and we should be prepared to pivot based on what is discovered and what provisions are made to the act.  This act also does not change the cost of service and is meant to protect individuals from large patient responsibility they did not agree to, as well as transparency in medical service costs.  

Part 1: No Surprise and Balance Billing

The No Surprises Act requires health plans and issuers to apply in-network cost-sharing terms and prohibits out-of-network providers, facilities, or providers of air ambulance services from billing individuals more than these in-network cost-sharing limits in 3 main scenarios: 

• A person gets covered emergency services from an out-of-network provider or out-of network emergency facility 
• A person gets covered non-emergency services from an out-of-network provider delivered as part of a visit to an in-network health care facility
• A person gets covered air ambulance services provided by an out-of-network provider of air ambulance services.

In-network facilities with IN providers currently don’t need to do anything different when accepting allowable amounts.
Out-of-network facilities and providers will need to provide a GFE.  This must cover expected charges, customized per patient and added to the patient’s chart.  More to follow on this in part 2.

In-network rates for out-of-network providers.  The processes for determining the patient’s cost sharing and the amount the plan must pay the OON facility or other OON provider are similar, with one significant difference.
First, if the care is provided in a state that participates in an All-Payer Model Agreement with the Centers for Medicare and Medicaid Services (CMS), then the amount the state approved under that Agreement as adequate payment for a given service is the amount the health plan must pay, and also serves as the basis for determining the patient’s cost sharing.
Maryland and Vermont are currently the only states that have these agreements with CMS and the agreements do not apply to all services or payers so the below rule will apply.
Secondly, many states have protections against balance billing, rules that establish procedures for calculating provider reimbursements.  The new federal law keeps intact these state-specific rules.
Finally, the act sets a process for determining both the patient’s cost-sharing responsibility for OON care and the plan’s payment obligation. The law establishes a general rule that the patient’s cost-sharing amount is based on the median in-network rate paid by all plans of the plan sponsor for similar items or services provided in the prior year, plus a cost -of living adjustment.
Example: Jerry participates in a self-insured health plan.  The plan requires 10% coinsurance for in-network emergency care and applies no deductible. Jerry receives emergency care from an OON physician in a state without an All-Payer Model Agreement.  The physician typically charges $5,000 for services rendered but the plan determines a typical allowable charge for such services from an in-network physician would be $2,500, which thus becomes the qualifying payment amount. Accordingly, the plan determines that Jerry’s co-insurance amount is $250.
As of 1/2022 states with laws already in place:
Emergency and Non-emergency laws by states:

Emergency & Non-emergency laws	Emergency situation laws only	Air Ambulance laws	No related laws
Arizona	Indiana	Montana	Alabama
California	Iowa	North Dakota	Alaska
Colorado	Missouri		Arkansas
Connecticut	Nevada		Hawaii
Florida	North Carolina		Idaho
Georgia	Pennsylvania		Kansas
Illinois	Vermont		Kentucky
Louisiana	Wisconsin		Nebraska
Maine			Ohio
Maryland			Oklahoma
Massachusetts			South Carolina
Michigan			South Dakota
Minnesota			Utah
Mississippi			Wyoming
New Hampshire
New Jersey
New Mexico
New York
Oregon
Rhode Island
Tennessee
Texas
Virginia
Washington
West Virginia

Patients that you are providing care for do have the option to continue seeing an OON provider, however a waiver must be provided and signed by the patient prior to balance billing.  CMS-consent form

If a provider drops out-of-network they must still provide INN rates for 90 days.  A provider must also maintain their directory. 

Part 2: Good Faith Estimate (GFE)

A GFE is simply an anticipated cost of care and services.  When scheduling a patient the individual fielding the call must ask if the patient intends to apply insurance benefits.  At this time, if the patient intends to bill insurance a GFE does not need to be issued.  The act states that each individual patient that is uninsured, self pay or not intending to use insurance benefits is to receive a GFE, which will be an administrative burden to practices.  A GFE must include:

• Patient name, date of birth and diagnosis
  • Acceptable to use tentative diagnosis (z or dx codes)
• Provider name, NPI, TIN and location of services
• Billing codes for each service
• Cover date of service or dos range if recurring services are to be rendered
  • Recurring up to 12 months

A practice can create their own GFE template including the required information.  Here is an example of a GFE from cms.gov: https://www.cms.gov/files/document/good-faith-estimate-example.pdf

At this time a patient/guarantor signature is not required, but should be considered as best practice in the case a complaint is filed that a patient never received a GFE.  

The act further states that the patient gets to determine how they receive the GFE and the provider must comply with their request.  Anyone held financially responsible is subject to receive a GFE.  Some forms of delivery:

• Paper
• Electronically (secure)
• Verbal (follow up must be done in writing)

With the GFE comes other guidelines that are required.  

• The convening provider (scheduling provider) is responsible for providing a full GFE by gathering estimates from all other providers or co-providers pertaining to the treatment of care
  • Estimates of co-provider must be provided within 1 business day of GFE request from scheduling provider
• Disclaimer on each GFE stating
  • Only an estimate and costs can change
  • Other services might be needed
  • Patient has the right to initiate dispute
  • GFE is not a contract and does not require patient accept services from provider

Deadlines and Timelines:
There are some confusions with how quickly a GFE is to be required.  The 10-3; 9-1 method is so far the most simplistic way to approach this. 

• 10-3 → if a scheduling call is 10 or more business days in advance; must provide GFE within 3 business days
• 9-1 → if a scheduling call is 3-9 business days in advance; must provide GFE within 1 business day
• If a scheduling call is less than 3 business days in advance; a GFE does not need to be provided, however best practice is still to provide a patient with a GFE in 1 business day
• If no appointment is scheduled and an individual requests a GFE; must provide GFE within 3 business days

Patient disputes and when to issue a new GFE 

If what is billed to the patient is more than $400 above the GFE the patient has the right to file a dispute ($25 administrative fee) with the Department of Health and Human Services.  The provider does have the ability to negotiate with the patient prior to come to a resolution.  If this is not done and the patient wins there could be additional fines and penalties given, the patient gets billed what was stated on the GFE and the provider will need to pay the $25 administrative fee the disputer was required to pay to initiate the dispute.  As a provider you might think to inflate the cost of services on the GFE.  Within the act there are statutes to prevent this as it is a “good faith” estimate and providers can be penalized for inflating costs.  With this all being said, when is a good time to update or provide a new GFE?

• Change in course of treatment
• Change in treatment costs
• Realization cost of services will exceed current GFE
• Change of diagnosis
  • Due to having to issue a tentative diagnosis on initial GFE.  If the diagnosis changes after care a new GFE should be provided
  • During the course of treatment if a diagnosis changes but the diagnosis does not change the treatment or cost; a second GFE is not required

What if my state has a surprise billing law?

The No Surprises Act supplements state surprise billing laws; it does not supplant them. The No Surprises Act instead creates a “floor” for consumer protections against surprise bills from out-of-network providers and related higher cost-sharing responsibility for patients. So as a general matter, as long as a state’s surprise billing law provides at least the same level of consumer protections against surprise bills and higher cost-sharing as does the No Surprises Act and its implementing regulations, the state law generally will apply. For example, if your state operates its own patient-provider dispute resolution process that determines appropriate payment rates for self-pay consumers and Health and Human Services (HHS) has determined that the state’s process meets or exceeds the minimum requirements under the federal patient-provider dispute resolution process, then HHS will defer to the state process and would not accept such disputes into the federal process.

As another example, if your state has an All-payer Model Agreement or another state law that determines payment amounts to out-of-network providers and facilities for a service, the All-payer Model Agreement or other state law will generally determine your cost-sharing amount and the out-of-network payment rate.

Other key facts

• ProBono care does not need a GFE
• Third Party Payer (funding source other than patient or insurance) it is unclear at this time if a GFE will be required.
  • If providing care after third party funding it is best practice to provide a GFE
• Insurance GFE: there are provisions within the act that may require GFEs to be submitted to insurance companies.
• Enforcement: there will be leeway until 2023 so don’t panic.  First step is showing an attempt at compliance.
• Non-medical fees (medical records) are not to be included in a GFE
• Providers and facilities must post notices in prominent locations within the office including front desk regarding patient’s right to GFE and disputes

from
https://www.coronishealth.com/blog/breaking-down-the-no-surprises-act/

2022 Updates You Need to Know

Medicare Clinical Laboratory Fee Schedule Private Payor Data Reporting – Delayed until 2023

The Protecting Medicare and American Farmers from Sequester Cuts Act delayed the Clinical Laboratory Fee Schedule private payor reporting requirement:

• Next data reporting period is January 1 – March 31, 2023
• Reporting is based on the original data collection period, January 1 – June 30, 2019

The Act also extended the statutory phase-in of payment reductions resulting from private payor rate implementation:

• No payment reductions for Calendar Years (CYs) 2021 and 2022
• Payment won’t be reduced by more than 15% for CYs 2023 through 2025

COVID-19 Vaccine & Monoclonal Antibodies : Changes for MA Plans Starting January 1, 2022

If you vaccinate or administer monoclonal antibody treatment to patients enrolled in Medicare Advantage (MA) plans on or after January 1, 2022, submit claims to the MA Plan. Original Medicare won’t pay these claims.

Pneumococcal Conjugate Vaccine, 15 Valent 

Medicare began covering pneumococcal conjugate vaccine,15 valent on July 16. CMS suggests submitting separate claims for this vaccine (HCPCS code 90671).

• Part A and B Medicare Administrative Contractors will hold claims for vaccines provided after December 31 until pricing is set
• CMS will deny claims for vaccines provided before July 16 

Average Sales Price Files: January 2022

CMS posted the January 2022 Average Sales Price (ASP) and Not Otherwise Classified (NOC) pricing files and crosswalks on the 2022 ASP Drug Pricing Files webpage.

Medicare FFS Claims: 2% Payment Adjustment (Sequestration) Changes

The Protecting Medicare and American Farmers from Sequester Cuts Act impacts payments for all Medicare Fee-for-Service (FFS) claims. The 2% sequestration cut that would apply to all Medicare rates beginning January 1, 2022 is postponed until April 1, 2022:

• No payment adjustment through March 31, 2022
• 1% payment adjustment April 1 – June 30, 2022
• 2% payment adjustment beginning July 1, 2022

New Telehealth POS codes

The Centers for Medicare & Medicaid Services (CMS) has published new guidance on the reporting of telehealth/telemedicine Place of Service (POS) codes.

For reporting Medicare telehealth services, CMS had recommended reporting the POS code that would have been reported if the service had been furnished in person. This recommendation was intended to allow CMS to make appropriate payments for services furnished via Medicare telehealth at the same rate as in-person services.

The POS code listed on a claim provides information on the location or setting for the services rendered. This information is necessary to pay claims correctly.

To meet the widespread use of telehealth during the public health emergency, CMS is now updating the 2022 POS code set by revising the description of existing POS code 02, Telehealth Provided Other than in Patient’s Home, and adding new POS code 10, Telehealth Provided in Patient’s Home. According to CMS’ October MLN Matters, the POS changes will go into effect on Jan. 1, 2022, and will be implemented on April 4, 2022.

POS 02: Telehealth Provided Other than in Patient’s Home

The location where health services and health-related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health-related services through telecommunication technology.

POS 10: Telehealth Provided in Patient’s Home

The location where health services and health-related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health-related services through telecommunication technology.

from
https://www.coronishealth.com/blog/2022-updates-you-need-to-know/

Surprise! It’s the No Surprises Act

Starting January 1, 2022, consumers will have new billing protections from receiving surprise medical bills for emergency services (including air ambulances) and non-emergency services provided at an in-network facility.

Patients’ out-of-pocket costs will be limited to the costs they would have paid if they had received services from an in-network doctor, hospital, or other health care provider.

Background – Surprise Billing and the Need for Greater Protections

Providers and facilities that are not part of a plan or issuer network (out-of-network or “OON” providers) usually charge higher amounts than the contracted rates the plans or issuers pay to in-network providers.

In many cases, the OON provider may bill the individual for the difference between the charge and the amount paid by their plan or insurance, unless prohibited by state law. This is known as “balance billing. A “balance bill” may come as a surprise for many people. A surprise bill is an unexpected bill from a health care provider or facility.

The No Surprise Act (NSA) will protect consumers from surprise medical bills by:

• requiring private health plans to cover these out-of-network claims and apply in-network cost sharing. The law applies to both job-based and non-group plans, including grandfathered plans
• prohibiting doctors, hospitals, and other covered providers from billing patients more than in-network cost sharing amount for surprise medical bills.

Emergency Services  – Surprise billing protections apply to most emergency services, including those provided in hospital emergency rooms, freestanding emergency departments, and urgent care centers that are licensed to provide emergency care. Without any prior authorization (i.e., approval beforehand).

Non-emergency services provided at in-network facilities – The NSA covers non-emergency services

provided by out-of-network providers at in-network hospitals and other facilities. Often, the doctors who work in hospitals don’t work for the hospital; instead, they bill independently and do not necessarily participate in the same health plan networks. 

Doctors and hospitals must not bill patients more than the in-network cost sharing amount for surprise bills

For services covered by the NSA, providers are prohibited from billing patients more than the applicable in-network cost sharing amount; a penalty of up to $10,000 for each violation can apply.

How will consumers know if a bill or claim constitutes a surprise medical bill? – It is up to both providers and health plans to identify bills that are protected under the NSA. Providers and facilities must post a one-page disclosure notice summarizing NSA surprise billing protections on a public website and give this disclosure to each patient for whom they provide NSA-covered services.

Some providers can ask consumers to waive rights

An exception to federal surprise billing protections is allowed if patients give prior written consent to waive their rights under the NSA and be billed more by out-of-network providers. 

Notice and Consent Waiver Not Permitted for:

• Emergency services
• Unforeseen urgent medical needs arising when non-emergent care is furnished
• Ancillary services, including items and services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology
• Items and services provided by assistant surgeons, hospitalists, and intensivists
• Diagnostic services including radiology and lab services
• terms and services provided by an out-of-network provider if there is not another in-network provider who can provide that service in that facility

Good Faith Estimates for Uninsured (or Self-pay) – Requirements for Providers & Facilities

When scheduling an item or service, providers and facilities are required to inquire about the individual’s health insurance status. The provider or facility must provide a good faith estimate of expected charges for items and services to an uninsured (or self-pay) individual, meaning an individual that:

• Does not have benefits for an item or service under a group health plan, group or individual health insurance coverage offered by a health insurance issuer, federal health care program
• Has benefits for such items/services under a group health plan, group or individual health insurance coverage offered by a health insurance issuer but does not seek to have a claim submitted to their plan, issuer, or carrier for the item or service.

The good faith estimate must include expected charges for the items or services that are reasonably expected to be provided together with the primary item or service, including items or services that may be provided by other providers and facilities. 

Determining Out-of-Network and Cost-Sharing Rates:

The total amount to be paid to the provider or facility, including any cost sharing, is based on:

• An amount determined by an applicable All-Payer Model Agreement under section 1115A  of the Social Security Act.
• If there is no such applicable All-Payer Model Agreement, an amount determined by a specified state law.
• If there is no such applicable All-Payer Model Agreement or specified state law, an amount agreed upon by the plan or issuer and the provider or facility.
• If none of the three conditions above apply, an amount determined by an independent dispute resolution (IDR) entity.

Patient-Provider Dispute Resolution

In a situation where an uninsured (or self-pay) individual receives a good faith estimate and then is billed for an amount substantially in excess of the good faith estimate

A patient’s bill will be determined eligible for the patient-provider dispute resolution process if the patient received a good faith estimate, if the process is initiated within 120 calendar days of the patient receiving the bill, and if the bill is substantially in excess of the good faith estimate.

HHS has defined “substantially in excess” as the billed charges being at least $400 more than the good faith estimate for any provider or facility listed on the good faith estimate.

Learn more at: https://www.cms.gov/nosurprises

from
https://www.coronishealth.com/blog/surprise-its-the-no-surprises-act/