DON’T MISS THIS WEBINAR – REGISTER NOW 

Thursday, January 25, 2018 – 2 pm – 3 pm EST

Prepare your organization to address the challenges faced by the industry’s complexity and the significant demands placed on coders and coding operations in 2018. In this webinar, you will learn about the steps you need to take, broken out in three-month increments to help you avoid coding pitfalls and optimize your coding performance. Learn from experts who code and audit over 30 million charts annually. This private webinar will put your organization on the path to successful coding and reimbursement in 2018.

Register Now

Presenters: Amber Broadwater, MBA, RHIA, LHRM, ICD-10 Trainer – Vice President of Client Services, Coding Division at MiraMed Global Services. Amber is the executive leader in charge of all HIM, coding and auditing functions at MiraMed. For seventeen years, Amber has held various positions throughout the revenue cycle continuum in administration, implementation, operations, product development, compliance and strategic planning for several of the largest healthcare companies in the industry. She has experience serving HHS, as a committee member on the Healthcare Technology Standards and Interoperability Framework and is an ICD-11 contributor for the World Health Organization.

Phil C. Solomon – Vice President of Marketing Strategy at MiraMed Global Services. Phil is the publisher of Revenue Cycle News and serves as the Vice President of Marketing Strategy for MiraMed, a revenue cycle outsourcing company. He has over 25 years’ of experience consulting on a broad range of healthcare initiatives for revenue cycle performance improvement by developing executable strategies for revenue enhancement, expense reduction, and clinical transformation.

Learning Objectives: 

  • What’s happening in healthcare today
  • 2018 coding focus area’s and why
  • The impact on the organization

DON’T MISS THIS WEBINAR – REGISTER NOW 

Thursday, January 25, 2018 – 2 pm – 3 pm EST

Register Now

For Questions – Contact: Webinars@MiraMedGS.com

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If you are familiar with how the healthcare revenue cycle operates, you should have heard the term “revenue integrity.”  It’s become an industry axiom and many provider organizations understand the value of having a focus on revenue integrity services.

Revenue Integrity Defined

In healthcare, revenue can be defined as the reimbursement made by an insurance payer to a provider for services, supplies, and other billable charges they provide. Reimbursement is based on a myriad of dynamic coding and billing rules and regulations. Merriam-Webster dictionary defines integrity as “firm adherence to a code of especially moral or artistic values; incorruptibility; completeness.” A revenue integrity strategy encompasses the complete capture of all legal and verifiable charges while being compliant with applicable rules and regulations.  It is a systemic approach that directs health organizations toward achieving operational efficiency, complete regulatory compliance, and total reimbursement.

The complexity of coding and billing requirements, along with changing rules and guidelines, leads to missed revenue collection opportunities and increased regulatory scrutiny. Effectually and compliantly capturing and billing all charges related to services is a challenge for healthcare providers and not doing so creates a risk of lost revenue where all the entitled revenue is not collected.

As healthcare costs increase and reimbursement from Medicare, Medicaid, and other major payers decrease, it is important for providers to shore up their financial position by accurately and correctly reporting and capturing all the revenue due to them.

Creating a revenue integrity program is essential to combating revenue leakage due to a myriad of issues such as problems with the charge description master (CDM), charge capture, billing compliance, coding, and much more. The difference between the amount of revenue providers are entitled to collect and the amount of reimbursement they actually receive significantly affect a provider’s bottom line and in the current state of healthcare, providers can ill afford to leave any monies uncollected.

Six Steps to an Effective Revenue Integrity Program

Today’s unsettled healthcare environment has put pressure on providers to stabilize their bottom lines, effectively transition to value-based care,  and prepare for the growth of consumerism. These changes, along with lower reimbursement rates, are forcing healthcare organizations to change the way they operate.

Healthcare consultant Vasilios Nassiopoulos, from Hayes Management Consulting, believes that forward-thinking revenue cycle leaders are reexamining the silo approach which has been traditionally followed for revenue capture. In his article, Six Steps to an Effective Revenue Integrity Program he outlined key strategies providers should take to ensure revenue integrity efforts cover the entire revenue cycle; front-end, mid-cycle and back office.

  1. Setup your organizational structure 

Developing a strong revenue integrity program begins with setting up the proper organizational structure. Traditional responsibilities of the revenue integrity team include monitoring and supporting gross revenue generation, along with revenue capture and reconciliation. The team must also help ensure regulatory compliance, prevent revenue loss, and conduct root cause analysis that minimizes scrutiny of your charge capture and CDM process from external entities.

You need a cohesive, focused organization to meet all these demands. A best practice structure has the senior revenue integrity leader reporting directly to the vice president of revenue cycle and having two people reporting directly to them: a director/manager revenue auditing and a director/manager process improvement/training.

The revenue auditing director leads a team of analysts, CDM maintenance subject matter experts (SME) and charge capture auditors. This group is responsible for ensuring the effectiveness of ongoing revenue integrity operations.

The process/improvement/training director works with process improvement specialists and trainers. This group takes the lessons learned from ongoing operations and incorporates them into reworked processes where necessary and developing a more effective training program and better communication methods to drive continuous improvement.

Establishing this type of organization may seem expensive, but consider that a mature, best practice revenue integrity department can drive between $1 million and $20 million annually in incremental net revenue improvement while ensuring that all three revenue streams remain accurate and compliant. The investment in your revenue integrity organization will more than pay for itself.

  1. Develop your project timeline

Once your organization is in place, develop a business case with a specific scope and implementation plan that will ensure long-term success and stability within the revenue cycle environment. The typical timeframe to get your program off the ground is 12 weeks.

The timeline should be broken into three phases.

  • The first phase involves discovery and evaluation of your current revenue cycle state and should answer the question, “Where are we?”Phase two includes establishing the vision, scope and plan of your revenue integrity program and answers the question, “Where are we going?” It involves looking to the future state of your program, evaluating staffing models, setting your monitoring, auditing, analysis and training approach while determining overall requirements including policies, procedures and technology. Phase three moves into implementation and completion of a detailed project plan and action items as defined in phase two.
  1. Decide on short and long-term goals

For any program to be successful, the team must all be working toward common goals. An effective revenue integrity program includes both short- (3-4 months) and long-term (4-12 months) goals.

Short-term goals include developing your annual work blueprint based on the Office of Inspector General (OIG) plan, reviewing the revenue integrity charter, determining optimal staffing needs, reviewing and updating job descriptions and policies, developing key performance indicator (KPI) methodology and targets and initiating recruiting of revenue integrity SME’s.

Long-term goals involve personnel recruiting, training, implementing charge capture performance improvement plans, initiating audits, evaluating tools and submitting a budget for enhancements, implementing scorecards for performance monitoring and aligning the program with organizational initiatives for revenue enhancements. You should also begin to develop a plan for year two of the program.

  1. Document functions within your program

Next, you need to establish the functions of your organization. Traditional compliance functions include an annual evaluation of the OIG plan, identifying high-risk areas that may be targeted for outside audits, monitoring areas that were in previous OIG plans and auditing charge capture and coding based on clinical documentation and claim review.

On the revenue side, your team needs to monitor revenue-generating departments, quantify missed revenue opportunities and conduct denial root cause analysis with mitigation planning, CDM management, charge-related audits and underpayment analysis.

You should also implement more progressive functions that can enhance your revenue integrity program. These include designating process improvement leads, training, management reporting, establishing technology liaisons, business analysts and vendor managers, and developing a more robust denials management group.

  1. Find and develop talent

The key to the success of your program will be the people who run it. That’s why it is imperative that you find and develop a team with healthcare knowledge and analytical skills.

Begin by bringing on someone with experience leading, developing and/or overseeing training programs specific to new hire orientation, technology implementation, and/or major process improvement and redesign.

The team members should be knowledgeable in all aspects of healthcare revenue cycle functions, the Centers Medicare and Medicaid Services’ state, local and federal regulations, medical records and terminology. You should also seek out professionals with the ability to assess data and processes to develop and implement performance opportunities. Look for people who can conduct and interpret qualitative and quantitative analyses and financial analysis.

It is also helpful to attract individuals who are conversant in healthcare economics and business processes, information systems, organizational development and healthcare delivery systems.

  1. Establish KPI’s

The strength of any program is having the ability to measure progress toward goals and this is especially important to ensure the success of your revenue integrity program. There are several KPI’s that you can set up to monitor your program.

Standard KPI’s include revenue and usage trending, go-live performance from a revenue perspective, charge capture opportunity/quantification and late charges as a percentage of total charge. You can also use contract management/underpayment tracking, external audit summary results, and results from charge recovery summaries.

Summary

Creating an effective revenue integrity program can be challenging, but the rewards in enhanced revenue and reduced compliance risks are worth the effort. Developing and implementing a solid revenue integrity strategy is resource draining and time-consuming, but if pursued diligently, it will pay for itself with a robust return on investment.

____________________

Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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DON’T MISS THIS WEBCAST – REGISTER NOW – https://attendee.gotowebinar.com/register/4452517804339382531

Thursday, January 11, 2018 – 2 pm – 3 pm EST

The top revenue cycle management professionals stay up-to-date with the fast-changing healthcare industry by attending educational events which create learning opportunities that help improve coding skills. Our webcast offers you tips and techniques delivered by experts in the field of coding. We will focus on healthcare’s latest developments, legislative updates and medical coding strategies to help you improve HIM performance.

Presenters:

Amber Broadwater, MBA, RHIA, LHRM, ICD-10 Trainer – Vice President of Client Services, Coding Division at MiraMed Global Services

Amber is the executive leader in charge of all HIM, coding and auditing functions at MiraMed. For seventeen years, Amber has held various positions throughout the revenue cycle continuum in administration, implementation, operations, product development, compliance and strategic planning for several of the largest healthcare companies in the industry. She has experience serving HHS, as a committee member on the Healthcare Technology Standards and Interoperability Framework and is an ICD-11 contributor for the World Health Organization.

Phil C. Solomon – Vice President of Marketing Strategy at MiraMed Global Services.

Phil is the publisher of Revenue Cycle News and serves as the Vice President of Marketing Strategy for MiraMed, a revenue cycle outsourcing company. He has over 25 years’ of experience consulting on a broad range of healthcare initiatives for revenue cycle performance improvement by developing executable strategies for revenue enhancement, expense reduction, and clinical transformation.

Learning Objectives: 

  • What’s happening in healthcare today
  • 2017 lessons learned
  • 2018 coding focus area’s and why
  • Tick & tying coding & clinical documentation
  • The impact on the organization

DON’T MISS THIS WEBCAST – REGISTER NOW 

Thursday, January 11, 2018 – 2 pm – 3 pm EST

https://attendee.gotowebinar.com/register/4452517804339382531

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From Humana to Highmark, Health Insurers Leave Insurance Marketplace, but Consumers are Undeterred

Recently, federal funds that assist Americans signing up for health insurance coverage under the Affordable Care Act (ACA) were cut by 40 percent and the ACA advertising budget was slashed from $100 million to $10 million.

These moves demonstrate the determination of the current administration and many in Congress to minimize the ACA insurance market and overturn the healthcare law. While these efforts appeared to stall initial sign-ups, they did not deter people. The fifth annual season for Americans to buy insurance under the ACA opened on Wednesday, November 1, 2017, with reports of crowds, technical difficulties and a public confused as never before by the political turmoil surrounding the law.

The funding decrease is problematic for the 2018 enrollment period, which just got started and will only last six weeks this fall instead of three months as in previous years. Sign-ups are taking place with many consumers confused by the political fighting in Washington over whether the law and its marketplaces will continue to exist.

Open Enrollment Begins

The federal website HealthCare.gov says, “2018 ACA Open Enrollment is here” and “Start a 2018 application now!” as both the federal and state insurance marketplaces attracted the year’s first customers. They came despite the 90 percent reduction in federal advertising about the sign-up window and the decision to send advance emails about enrollment to millions fewer Americans than in past years.

The emails went only to people with current health plans through marketplaces created under the law, leaving out most of the names in a database of about 25 million consumers who once had such coverage or at some point explored the federal website.

Nonetheless, plenty of people in certain states appeared eager to register on November 1 at places still offering in-person assistance through the navigator program.

In the first few days of open enrollment, the number of participants swelled compared with past years, according to federal officials who spoke on the condition of anonymity because the administration has yet to release official numbers.

More than 200,000 Americans chose a plan on November 1, the day open enrollment began, according to one administration official. That’s more than double the number of consumers who signed up on the first day of enrollment last year. More than one million people visited HeathCare.gov, the official said, which amounts to roughly a 33 percent increase in traffic compared with 2016.

These figures capture only a portion of the nation’s overall ACA enrollment because they encompass states that either uses the federal healthcare marketplace or rely on its website for their consumers to sign up for coverage. More than a dozen states and the District of Columbia run their own programs and do not use HealthCare.gov.

Many industry stakeholders were concerned that consumers wouldn’t sign up for coverage because Congress had tried to repeal it multiple times this year. But on opening day, many state exchange officials said that enrollment had exceeded their projections.

Connect for Health Colorado spokesman Luke Clarke said state officials had expected that 2,700 residents would log on to their exchange on November 1, but more than 4,000 did. “It’s way ahead of where we were last year, and a big surprise,” he said.

That same day in Connecticut, 1,596 residents enrolled in qualified health plans on the state exchange, while another 2,293 people either completed Medicaid applications or determined that they were eligible for the federal entitlement program. Access Health CT CEO Jim Wadleigh said in a statement that the state’s call center and website experienced a 15 percent increase in volume compared to opening day last year.

It’s all well and good that 2018 enrollment has been initially brisk, but what will the enrollment figures look like when the period ends on December 15, 2017, and how many insurers have made insurance plans available at a reasonable cost to consumers?

Healthcare Insurance Marketplaces

Many critics of the ACA say the law is “collapsing” and claim many insurers have left the ACA’s insurance exchanges or state-based online marketplaces where people can buy individual health insurance policies.

Today, it appears that about one-third of counties are projected to have just one insurer available for their insurance exchanges. That leaves 2.9 million consumers with little choice but to select the only insurer available in their county, which, ultimately, could put them in a financial bind due to high costs.

That statistic was echoed in a May 2017 editorial by former Health and Human Services Secretary Tom Price, in which he portrayed the ACA as a house on fire and “many of our fellow Americans are trapped inside.”

Some insurers already have decided to hike their 2018 premiums more than they would otherwise to position themselves for a possible adverse decision affecting the ACA. Consumer choice is limited due to insurers leaving the insurance marketplace. As of the November 1, 2017, open enrollment date, the following insurers have left the 2018 marketplace:

ATRIO Health Plans

Oregon – 6 counties

 Aetna

Delaware – 3 counties

Iowa – 76 counties

Nebraska – 93 counties

Virginia – 51 counties

 Anthem

California – 30 counties

Indiana – 92 counties

Kentucky – 61 counties

Maine – 16 counties

Missouri – 17 counties

Ohio – 87 counties

Virginia – 61 counties

Blue Cross Blue Shield Healthcare Plan of Georgia

Georgia – 73 counties

Blue Cross Blue Shield of Kansas City

Kansas – 2 counties

Missouri – 30 counties

BridgeSpan Health

Idaho – 44 counties

Oregon – 17 counties

Washington – 8 counties

Cigna Healthcare

Maryland – 24 counties

Community Health Plan of Washington

Washington – 14 counties

Health Tradition Health Plan

Wisconsin – 14 counties

Highmark

Pennsylvania – 7 counties

Highmark Health Insurance Company

Pennsylvania – 4 counties

Humana

Florida – 7 counties

Georgia – 9 counties

Illinois – 30 counties

Kentucky – 9 counties

Louisiana – 7 counties

Michigan – 9 counties

Missouri – 5 counties

Mississippi – 32 counties

Ohio – 7 counties

Tennessee – 30 counties

Texas – 10 counties

Innovation Health Insurance

Virginia – 19 counties

LifeWise Health Plan of WA

Washington – 4 counties

MDwise Marketplace

Indiana – 92 counties

Medica Health Plans

North Dakota – 49 counties

Minuteman Health, Inc.

New Hampshire – 10 counties

Massachusetts – 9 counties

Molina

Utah- 7 counties

Washington – 6 counties

Wisconsin – 30 counties

Northwell Health w/CareConnect

New York – 8 counties

Optima Health

Virginia – 17 counties

Premera Blue Cross

Washington – 1 county

Premier Health Plan

Ohio – 9 counties

Prominence Health

Nevada – 7 counties

Texas – 3 counties

Regence BlueShield

Washington – 2 counties

UnitedHealthcare

Virginia – 32 counties

Wellmark

Iowa – 4 counties

Final Thoughts

Clearly, the decisions by insurers to pull out of the insurance exchanges have been driven by the financial risk and an uncertain outlook for the marketplace. Insurers face continued uncertainty even in the midst of open enrollment. Some insurers explicitly have factored this uncertainty into their initial premium requests, while other companies say if they do not receive more clarity or if cost-sharing payments stop, they plan to either refile with higher premiums or withdraw from the market altogether.

What does this mean for consumers? They should expect a reduction of choices for insurers offering plans in their area and higher insurance rates due to the uncertainty of the marketplace.

____________________

Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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The level of respect, compassion and sensitivity to healthcare consumers is increasingly being used to judge patient satisfaction regarding quality of care and is an important component of a healthcare system’s care delivery.

There is an increasing focus on encouraging individuals to be more involved in their care, which has prompted providers to deliver healthcare in a more patient-centered way. Patient-centered care is focused on adapting services around the needs of consumers. These efforts are designed to engage patients, their family members and caregivers to achieve better clinical outcomes.

Today, patients expect to receive respectful treatment, enough information to make good decisions about their care, clear and abundant communication and quality clinical outcomes. Positive patient and staff experiences lead to good health outcomes through clinical effectiveness, which drives high levels of patient satisfaction and loyalty.

The new patient-centric care model is not without its challenges. The cost of delivering healthcare is rising quickly, and the consumer must now shoulder more of the costs. The new financial demands on patients have created a conundrum. Patients are enjoying newly implemented consumer-driven healthcare, but they are now paying handily for it. A study by Black Book™ indicates that since 2015, patients have experienced a 29.4 percent increase in both deductible and maximum out-of-pocket costs.

The Savvy Healthcare Consumer

A patient’s healthcare journey is a complex one. Beginning with pre-care, treatment, and ending with a measure of patient satisfaction, the emerging concept of patient-centric healthcare has many touchpoints that can break down and cause dissatisfaction. To satisfy savvier consumers, industry experts must address the gaps in the current patient experience by focusing on the entire patient healthcare continuum, from initial patient decision-making, scheduling, registration, administrative simplification, price transparency and effective consumer payment methods.

In March 2016, the Healthcare Information and Management Systems Society (HIMSS) Revenue Cycle Improvement Task Force study, A Roadmap to The Patient Financial Experience of the Future, reported that “the growth in consumer financial responsibility has led to the expected billing and collections challenges that were known to be weak points of a patient-centric revenue cycle. Many industry experts did not consider how much more information a patient with greater financial responsibility would come to expect.”

Traditional models for accessing and sharing health insurance, financial and clinical information, and a lack of interoperability between the systems that support these models are insufficient to meet the increasing demand for real-time information and price transparency.

As consumers shoulder larger amounts of financial responsibility for their healthcare, they begin to view healthcare as a retail experience, which means:

  • They are likely to transfer their expectations as a typical retail consumer to their healthcare experience.
  • More patients are researching their healthcare options before deciding where to go for care.
  • They are leveraging technology to determine the level of care available to them.
  • They expect to have pricing and quality or patient satisfaction information at their fingertips.
  • They think they should be able to use this and other information to compare providers in the same way they might compare consumer products they would purchase online.

Providers Address Consumerism with New Payment Financial Solutions

The new era of patient consumerism demands more technology-driven financing options, engaging patients early, analyzing consumers’ propensity to pay, managing expectations and genuine cost transparency.

Black Book announced key findings from its 2017 Revenue Cycle Management surveys part of a larger study of trends in consumer satisfaction and patient experiences and payment challenges and strategies for healthcare providers.

They determined that 83 percent of surveyed providers plan to meet the rise in patient consumerism with more retail-like technology solutions and practices.

“Emerging healthcare pay trends reveal the opportunity to help patients better anticipate, manage and track the costs of their care,” said Doug Brown, Managing Partner of Black Book. “Innovative patient-friendly payment solutions that meet consumer preferences and enable fast transactions are playing a key role in this transition.”

Black Book conducted two sets of focused polls in the second and third quarters of 2017 with both patients and providers. Consumer panel surveys aimed to determine how patient responsibility for medical costs, which has shifted from employers to patients, is impacting uncollected provider revenue. Black Book found that since 2015, patients have experienced a 29.4 percent increase in both deductible and maximum out-of-pocket costs, with an average deductible for consumers at $1,820 and out-of-pocket costs rising to over $4,400. The combined surveys included 2,698 providers and a focus group of 850 healthcare consumers with high deductible health plans.

Survey findings from 1,595 physician practices, 202 hospitals and 49 health systems reveal profit margins continue to be impacted negatively by traditional collection solutions, steering 82 percent of medical providers and 92 percent of hospitals to eliminate time-intensive, error-prone, manual effort to implement back-end process and reconcile bills by the fourth quarter of 2018. With millions of dollars of unpaid medical bills, many providers are instituting new processes and technologies to recover the monies owed them.

“Employing these solutions at the front end of the revenue cycle has given patient risk to providers and the attention has turned to establishing funding mechanisms to benefit not only the hospital or physician but the consumer,” said Brown. “Patients truly are the new payers.”

Results also determined that in the first half of 2017, nearly 62 percent of medical bills were paid online and 95 percent of consumers polled would pay online if the provider’s website had the option.

Seventy-one percent of patients also reveal that mobile pay and billing alerts have improved their actual satisfaction with the provider.

Online estimation, payment plan administration and on-demand instructions support (all of which were ranked by consumers in the top five improvements providers could make to improve satisfaction) produce more cost transparency for consumers. “For providers, that brings faster posting and collection of payments without manual processing errors,” added Brown.

Guest pay (allowing spouses, family members, friends, attorneys and others to pay patient bills without accessing patient medical records) is also improving consumer satisfaction. Fifty-nine percent of consumers appreciate the convenience and simplicity of online payments without the hassles of registration and passwords.

Summary

Industry stakeholders have acknowledged the need for health plans and providers to share information with consumers in a more coordinated fashion to enable improved consumer financial activities. The seamless connection between healthcare financial and clinical systems is critical to respond to the new revenue cycle demands. Consumers expect an improved financial experience in healthcare and providers must step up to provide the healthcare services, payment systems and technology to serve patients at higher levels.

____________________

Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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Join Us for This Special One of a Kind Webinar. Learn Inside Secrets from a Vendor Who Codes Over 2 Million Charts Per Month

Date – November 2, 2017, 2:00 to 3:00 pm EDT

Register  today:                  https://attendee.gotowebinar.com/register/3633988570364620289

Learn about how to stay in compliance and maximize reimbursements – Medicare Advantage makes up 31 percent of total Medicare spending, serves over 17 million enrollees and it is expected to double in size by 2024. The average monthly premium for a Medicare Advantage plan will decrease while enrollment in Medicare Advantage is projected to reach a new all-time high in 2018.

These changes, plus the overall complexity of the program further complicate HCC coding. Why wait until year end to review your HCCs? Learn the secrets MiraMed uses to catch coding errors, maintain compliance and improve revenue capture.

You will learn:

  • What’s happening in healthcare today
  • The type and specialty of the organization
  • The scope of HCC audit project, why there was a need for the external HCC audit and coding work.
  • The client’s baseline prior to HCC audit
  • The findings of coding and HCC audit
  • The impact to the organization

Presenters:

Amber Broadwater – MBA, RHIA, LHRM, ICD-10 Trainer – Vice President of Client Services, Coding Division at MiraMed Global Services.

Phil C. Solomon – Vice President of Marketing Strategy and Thought Leadership at MiraMed Global Services and Publisher of Revenue Cycle News Blog.

Save Your Spot – Register today: 

https://attendee.gotowebinar.com/register/3633988570364620289

For more information, contact Phil Solomon at phil.solomon@miramedgs.com

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Safety-net hospitals rely on disproportionate-share hospital (DSH) payments to help cover uncompensated care costs and underpayments by Medicaid. The Affordable Care Act (ACA) anticipated that insurance expansion would increase safety-net hospitals’ revenues and planned to reduce DSH payments accordingly.

However, decreases in uncompensated care costs resulting from the ACA insurance expansion may not offset the Act’s DSH reductions after all due to the high number of people who will remain uninsured, low Medicaid reimbursement rates, and medical cost inflation.

The DSH payment program was established in 1981 and provides over $20 billion each year in special Medicare and Medicaid funding to hospitals that treat a disproportionate share of indigent patients. Over 3,000 hospitals nationwide currently receive DSH payments.

The ACA originally called for reductions to DSH payments between 2014 and 2020, assuming that ACA coverage expansions would reduce the need for the funding of uncompensated care. Ensuing legislation delayed DSH payments cuts until the fiscal year 2018, which began October 1, 2017. Under the current structure, the DSH program funding will be cut by a total of $43 billion between fiscal years 2018 and 2025.

DSH Payments to Provider Hospitals

DSH payments are statutorily required to offset hospitals’ uncompensated care costs in order to improve access for Medicaid and uninsured patients and improve the financial stability of safety-net hospitals.

States began making Medicaid DSH payments in 1981. As states had broader discretion over hospital payment, Congress became concerned that this shift might threaten hospitals serving large numbers of Medicaid beneficiaries and the uninsured. In response, in 1981 Congress required states to “take into account” the situation of hospitals serving a disproportionate share of low-income patients when designing payment systems (§1902(a)(13)(A)(iv) of the Social Security Act).

Limits on DSH Allotments and Payments

When Congress first required states to make DSH payments, states had discretion as to how the funds were paid, and in turn, states were slow to make payments. In the Omnibus Budget Reconciliation Act (OBRA) of 1986, Congress clarified that Medicaid’s hospital payment limitations did not apply to DSH, and then in 1987 required states to submit state plan amendments authorizing DSH payments. At about the same time, a 1985 federal regulation permitted states to use both public and private donations as sources of non-federal Medicaid financing. The 1987 policy guidance indicated that taxes imposed on only Medicaid providers could also be used to finance Medicaid (National Health Policy Forum 2002). This combination of unlimited DSH payments and financing flexibility generated significant growth in DSH spending. From 1990 to 1992, the total amount of DSH payments increased from $1.3 billion to $17.7 billion (Urban Institute 1998).

As DSH spending increased, Congress grew concerned over the level of DSH spending and the possibility that some states were misusing DSH funds by making large DSH payments to state-run hospitals.  Congress addressed these concerns by enacting national and state-specific caps on the DSH funds and creating hospital-specific limits equal to the actual cost of uncompensated care for hospital services provided to Medicaid enrollees and uninsured individuals.

State DSH Payment Requirements

States have flexibility in determining which hospitals receive DSH payments and how those payments are calculated. States may make DSH payments to DSH hospitals if they meet one of two criteria specified in federal statute:

  • The hospital has a Medicaid utilization at least one standard deviation above the mean for hospitals in the state that receive Medicaid payments, or
  • The hospital has a low-income inpatient utilization more than 25 percent.

States’ DSH payment practices must be outlined within their Medicaid state plans. Federal statute requires that minimum payments to DSH hospitals must be determined using one of the following methodologies:

  • The Medicare DSH adjustment methodology,
  • A methodology that increases DSH payments in proportion to the extent that a hospital’s Medicaid utilization exceeds one standard deviation above the mean, and
  • A methodology that varies by hospital type and that applies equally to all hospitals of each type and is reasonably related to Medicaid and low-income utilization.

ACA Medicaid DSH Allotment Reductions

Under the ACA, federal DSH allotments were to begin reductions beginning in 2014 to account for the decrease in uncompensated care anticipated under health insurance coverage expansion. However, since 2010, several pieces of legislation have been enacted, thus delaying the ACA’s Medicaid DSH reduction schedule:

  • The Middle-Class Tax Relief and Job Creation Act of 2012 (P.L. 112-96), enacted on February 22, 2012, extended the reductions to FY 2021.
  • The American Taxpayer Relief Act of 2012 (P.L. 112-240), enacted on January 2, 2013, extended the reductions to FY 2022.
  • The Bipartisan Budget Act of 2013 (P.L. 113-67), enacted on December 26, 2013, delayed the onset of reductions until FY 2016 by eliminating the FY 2014 reduction and adding the FY 2015 reduction to that for FY 2016; also extended the reductions to FY 2023.
  • The Protecting Access to Medicare Act of 2014 (P.L. 113-93), enacted April 1, 2014, eliminated the FY 2016 reduction, thus delaying the reductions until FY 2017; also adjusted amounts of reductions in future years and extended them to FY 2024.
  • The Medicare Access and CHIP Reauthorization Act of 2015 (P.L. 114-10), enacted on April 16, 2015, eliminated the FY 2017 reduction, which delayed the reductions until FY 2018, adjusted amounts of reductions in future years, and extended them to FY 2025.

As a result, the schedule below reflects the pending amounts for the Medicaid DSH reductions:

  • $2.0 billion in FY 2018;
  • $3.0 billion in FY 2019;
  • $4.0 billion in FY 2020;
  • $5.0 billion in FY 2021;
  • $6.0 billion in FY 2022;
  • $7.0 billion in FY 2023;
  • $8.0 billion in FY 2024; and
  • $8.0 billion in FY 2025.

The Centers for Medicare and Medicaid Services (CMS) published its final rule describing its methodology for implementing the Medicaid DSH allotment reductions beginning in 2014 and 2015. The reductions were authorized by meeting the following:

  • One-third on its relative level of uninsurance;
  • One-third on the extent to which it targets DSH payments to hospitals with high Medicaid utilization; and
  • One-third on the extent to which it targets DSH payments to hospitals with high levels of uncompensated care.

Since there have been delays in the onset of the DSH reductions, the payment methodology necessary to implement them has not been rolled out. The current payment methodologies are no longer valid, creating a conundrum for CMS. They must now scurry to create a new payment methodology before the DSH payment reductions go into effect in 2018.

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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Healthcare stakeholders should be educated on the policy proposals contained in the Graham-Cassidy Healthcare Bill proposal.  This updated chart provides a comparative analysis of the Graham-Cassidy Bill, the Better Care Reconciliation Act (BCRA), the American Health Care Act (AHCA) and the ACA.

The chart highlights each bill’s treatment of a number of core issues, including:
•    Insurance subsidies
•    Individual mandate
•    Employer mandate
•    Young adults
•    Essential health benefits
•    Prohibition on annual and lifetime limits
•    Age-rated limit
•    Health status premium underwriting
•    Preexisting condition coverage
•    Relief for high-risk individuals
•    Medicaid expansion
•    Traditional Medicaid
•    Health Savings Accounts (HSAs)
•    Tax provisions

Healthcare_Comparison_Chart_9-18-2017

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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Healthcare providers, if you serve Medicare, Medicaid and Children’s Health Insurance Program (CHIP) patients in the counties and geographical areas impacted by Hurricane Irma and Hurricane Harvey, or see patients who have been displaced from their homes in these areas who are in need of care, you need to know how government payers are responding to the crises, as well as the compliance implications of their actions for your facilities.

“Hurricane Irma has proven to be highly destructive and poses a significant threat to the health and safety of all Americans in its path,” said Health and Human Services (HHS) Secretary Tom Price, MD.  “HHS has pre-positioned assets and personnel who can rapidly deploy to assist local responses in Florida to Hurricane Irma, and this declaration will help ensure that access to care is maintained for those with Medicare and Medicaid.”  Secretary Price also authorized emergency efforts in Texas in the aftermath of Hurricane Harvey.

Beyond deployment of emergency resources, Secretary Price has declared a public health emergency in Florida, Georgia, South Carolina, Puerto Rico and the U.S. Virgin Islands in response to Hurricane Irma and in Texas and Louisiana in response to Hurricane Harvey.

The public health emergencies have enabled the Centers for Medicare and Medicaid Services (CMS) to issue several blanket programmatic waivers of certain requirements for providers who care for Medicare, Medicaid and CHIP beneficiaries, based on Section 1135 of the Social Security Act.  The blanket waivers are designed to offer beneficiaries—including those who are evacuated, transferred or dislocated as a result of the hurricanes—access to medical care during the emergency.  The waivers give hospitals, skilled nursing facilities (SNFs), other healthcare facilities and clinicians more flexibility to deliver emergency and other healthcare services in the wake of the disasters.

The flexible temporary policies regarding specified requirements are designed to bolster the effectiveness of the emergency response by, for example, allowing hospitals to share medical records without the usual restrictions and permitting doctors accredited by other states’ Medicaid programs to provide emergency treatment.  Individual facilities in the impacted areas or those treating patients evacuated from the impacted areas need not apply for these blanket waivers.

Following is a summary of the blanket waivers for both Hurricane Irma and Hurricane Harvey, under Sections 1135 or 1812(f) of the Social Security Act (for the impacted areas in the U.S. Virgin Islands, Puerto Rico, Florida, Georgia, South Carolina, Texas and Louisiana).

  • 1812(f):  Waives the requirement for a three-day prior hospitalization to obtain coverage of a stay in a SNF providing temporary emergency coverage of SNF services without a qualifying hospital stay for individuals evacuated, transferred or otherwise dislocated in 2017.  For certain beneficiaries who have exhausted their SNF benefits, the waiver authorizes renewed SNF coverage without first having to start a new benefit period.
  • 483.20:  Provides relief to all impacted SNFs on the timeframe requirements for Minimum Data Set (MDS) assessments and transmission.
  • 484.20(c)(1):  Provides relief to all impacted home health agencies on the timeframes related to OASIS transmission.
  • Waives the requirement for Critical Access Hospitals to limit the number of beds to 25 and limit the length of stay to 96 hours.  This is a blanket waiver for all impacted hospitals.
  • Waives the requirement for Inpatient Prospective Payment System (IPPS) hospitals to house acute care patients in distinct units, where the distinct part unit’s beds are appropriate for acute care inpatients.  The IPPS hospital should bill for the care and indicate in the patient’s medical record that the patient is an acute care inpatient being housed in the excluded unit due to capacity issues related to the hurricane.  This is a blanket waiver for all IPPS hospitals located in the affected areas that need to use distinct part beds for acute care patients as a result of the hurricane.
  • Waives the requirement for a face-to-face visit with a physician, a new physician’s order and new medical necessity documentation for suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) when DMEPOS are lost, destroyed, irreparably damaged or rendered unusable.  Under this waiver, suppliers must continue to provide a narrative description on the claim explaining the reason why the equipment must be replaced.  They are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged or otherwise rendered unusable as a result of the hurricane.
  • Allows coverage for replacement prescription fills for a quantity up to the amount originally dispensed of covered Part B drugs in instances in which the dispensed medication was lost or rendered unusable by damage due to the hurricane.

For providers in the states of Texas and Louisiana, CMS has extended the September 1, 2017 deadlines to October 2, 2017 for the following:

  • Applications for sole community hospital (SCH) status
  • Written requests for low-volume hospital status in order to receive the low-volume hospital payment adjustment for discharges in fiscal year (FY) 2018
  • Applications for reclassification to the Medicare Geographic Classification Review Board (MGCRB)
  • Extensions for IPPS Wage Index revisions

Please note that, according to CMS, these temporary emergency policies apply to timeframes specified in the waiver(s) issued under Section 1135 of the Social Security Act.  More information is available on the CMS website here.

For instances in which there is no blanket waiver, providers can request an individual Section 1135 waiver by following the instructions available here.  According to CMS, “specific waivers granted as a result of the emergency or disaster may be retroactive to the beginning of the emergency or disaster if warranted.  CMS also has the authority to exercise certain flexibilities, which are agency policies or procedures that can be adjusted under current authority—and generally speaking, can be adjusted without reprogramming CMS’s systems.”

The effects of these natural disasters on care delivery, as well as billing and reimbursement, will not only be felt for the short term, but are likely to ripple through your organizations for at least several months and possibly more than a year.  We encourage you to check the Hurricane page on the CMS website frequently for updates.  Questions regarding claims can be directed to your Medicare Administrative Contractor on its toll-free number, which can be found here.  ICD-10 coding advice from the Centers for Disease Control and Prevention in the aftermath of the disasters is available here.

Read more updates: MiraMed eAlerts

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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Hurricane Harvey wreaked havoc in southeastern Texas last week and created a public health crisis.  The tropical cyclone or what is called a category four hurricane caused unprecedented and catastrophic flooding in the southeastern part of the state.  It was the first major hurricane in the U.S. since Wilma in 2005, a category five hurricane with winds of up to 185 mph.

Harvey is the wettest storm on record in the contiguous United States and is “almost certain” to be at least the third worst storm in U.S. history when it comes to damage costs, according to Enki Research.  The firm’s current estimate ranges from $48 billion to $75 billion, with an average of $57 billion.  However, those numbers are subject to change with each passing day.  “The computer models we normally use to do estimates for hurricanes don’t work that well for this kind of a storm,” Chuck Watson, the director of research and development at Enki Research, said.

The resulting floods inundated hundreds of thousands of homes, displaced more than 30,000 people and prompted over 13,000 rescues.  Medical services and hospitals were taxed beyond capability, especially since many hospitals and medical facilities were closed and evacuated.

Though Hurricane Harvey pounded Texas with a national rainfall record for a tropical storm, crisis management coordination between the state and Texas hospitals ensured care was minimally interrupted.  The South East Texas Regional Advisory Council (SETRAC) claims that roughly 90 percent of healthcare facilities will return to full service by October, according to STAT News.

The outcome could have been much worse, considering the nature of the storm.  Houstonians pulled together and weathered the storm with great determination.  Addressing Harvey’s effects required a resourcefulness that no other catastrophe has necessitated.  The storm has challenged a comprehensive disaster plan the city and surrounding counties had prepared.  The devastation so far has been unimaginable.

The host of National Public Radio’s (NPR) show, All Things Considered, Kelly McEvers spoke with Darrell Pile, CEO of SETRAC which runs the catastrophic medical operations center which will offer a perspective of the medical challenges experienced during the storm.  This interview has been edited for length and clarity.

NPR Interview Highlights

While the storm has largely left Houston, the flooding continues.  What is the situation with the hospitals you are working with?

The flooding is devastating, and we have at least two reservoirs where water is having to be released and is, in fact, flooding neighborhoods as we speak and has placed three hospitals in harm’s way.

The three hospitals are monitoring the water coming from the two reservoirs very closely, and they could, depending on the flow of the water, find that they could become inaccessible to EMS agencies.  We are tracking that very closely.

The situation with residents in their homes—some are on the second floor of their homes—the evacuation process [for those neighborhoods] continues, and, as a result, it is unclear what the demands on the health care system may be.  However, most hospitals are up and fully functional, and we believe we can handle any new demands that happen today or tomorrow.

Has the catastrophic medical operations center ever handled anything like this?

No.  The phone lines at one point became inundated.  The amount of resources needed began to exceed what we had available.  The calls included patients needing dialysis who might be at home.  It included hospitals saying we need to evacuate.  One call was asking for 50 wheelchairs to be sent to a shelter.  We did not have 50 wheelchairs left.  Fortunately, our governor declared a disaster and the president declared a disaster and resources have been brought in from all over the state and all over the nation to help us.

How did you get those 50 wheelchairs?

I am not clear on how they ended up getting the 50 wheelchairs, but I can tell you, it can be accomplished just through one or two tweets to Houstonians.  Those with wheelchairs perhaps in their attic or stored [elsewhere] could bring an abundance of wheelchairs, perhaps more than you even need.  So there are methods to solve every problem.  It is just having enough people to make the calls or to be innovative and creative to solve the problems.  This community has come to the call.

A number of hospitals did evacuate, either prior to the storm or during. How difficult is it to evacuate a hospital?

It’s not as simple as pulling up a bus or a convoy of ambulances and moving patients from one hospital to another hospital.  My organization makes sure that the receiving hospital meets the need of every single patient they agree to receive.  As a result, the evacuation of a hospital might mean we must identify ten different hospitals to meet the unique needs of each patient.

Every day, three times per day, we have hospitals electronically advise us of beds that they have available and the type.  So a pediatric patient goes to a pediatric bed.

Moreover, we have also spent time making sure the receiving hospital is not in harm’s way so that the patient would not have to be evacuated twice.  We have worked with the [Texas] Department of State Health Services to also identify hospitals with beds available in cities such as Dallas or San Antonio or Austin or even further away so that a patient doesn’t move twice.

Some Houston hospitals added flood protections as a result of other devastating storms, including Allison in 2001. Have those worked?

Absolutely.  We had a situation where in prior storms, water came into a tunnel system that connects the Texas Medical Center hospitals.  [The tunnels] make it easier to go from one hospital to another hospital.  However, waters came in and flooded every hospital through that tunnel system.

The Texas Medical Center invested in submarine-type doorways, and when there is a risk of flooding, they now close those doorways.  So each hospital is compartmentalized.  As a result, this storm—even though flooding devastated our community, it did not devastate Texas Medical Center.  So, congratulations to the Texas Medical Center.

Do the hospitals have the staff they need right now?

I can imagine some of the hospitals have fewer employees available to staff the hospital.  Some members of their workforce have lost everything—their homes destroyed, their automobiles destroyed.

Tomorrow, we will be holding a meeting to discuss what our hospitals need.  And from there we will be identifying where we need to place nurses.  We have an abundance of nurses from throughout Texas who have offered to help.  We also have an abundance of physicians who have offered to help.  Now it’s a matter of making sure we place them in the proper facilities.

The Aftermath of Hurricane Harvey

Hurricane Harvey began with raging winds, but its legacy will be the seemingly endless stream of water that swamped parts of Houston and the surrounding area.  Harvey whipped up tons of water from the sea and hurled it down on the country’s fourth most populous city, drowning vast tracks of the landscape and battering it with almost a year’s worth of rainfall in less than a week.

Houstonians are strong and will rebound from Harvey’s devastation.  So will its hospitals and medical community.  The rebuilding process will not happen without the assistance of those within and outside the healthcare industry.  The American Hospital Association (AHA) has been supporting colleagues at the Texas Hospital Association as they work with hospitals and health systems, as well as local and federal agencies, to respond to the ongoing disaster.

Concerned citizens can help relief efforts in a number of ways:

Blood Donations: The American Association of Blood Banks (AABB) is urging eligible donors, especially those with type O-positive blood, to make donation appointments as soon as possible.  Those interested in donating may contact the following organizations to find a local blood drive and schedule an appointment:

Texas Hospital Association Assistance Fund: The Texas Hospital Association has established an assistance fund to help hospital employees who experienced significant property loss or damage.  Administrative services are being provided in kind, so 100 percent of donations can be used to assist individuals in need. AHA has contributed an initial $50,000 to get the fund started.

For more information or to make a donation, visit https://www.tha.org/Harvey/ReliefFund.  For additional details, visit www.tha.org/harvey.

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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New Rescheduled Date – Don’t Miss This Webinar: HCC Coding and Auditing Strategies

by Phil C. Solomon August 30, 2017

Don’t gamble on your risk adjustment HCC coding. Learn about how to stay in compliance and maximize reimbursements Rescheduled date – September 28, 2017 | 2:00 to 3:00 pm EDT Register today: Webinar: HCC Coding and Auditing Strategies Do you have risk-adjusted physician services contracts for your Medicare Advantage patients? Then read on…you may be leaving […]

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CMS Seeking Comments for Abandoning Cardiac Bundles and Limiting CJR Model

by Phil C. Solomon August 18, 2017

CMS Seeking Comments for Abandoning Cardiac Bundles and Limiting CJR Model The proposed rule change posted to the Federal Register on August 10, 2017 indicates the Centers for Medicare and Medicaid Services (CMS) will rescind the regulations governing two mandatory bundled payment programs, the Advancing Care Coordination through Episode Payment Models (EPMs) and Cardiac Rehabilitation […]

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