Client News Coverage

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

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

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

Ongoing education and the right tools and resources can help physicians as they face increased coding responsibilities.

Twenty-five years ago in outpatient settings, doctors dictated notes using narratives and appropriate medical jargon to describe a patient’s presenting diagnoses. Samuel L. Church, MD, MPH, CPC, CRC, CPC-I, Georgia-local medical director at Aledade, Inc, remembers that coding happened after the dictation, apart from the physician. “It kind of happened magically,” he says. “We never had to worry about [coding] then. We were concentrating on doing good medicine.”

Today, however, the landscape has shifted. Physicians are often tasked with at least some of the coding responsibilities as they input notes into EMRs. “We get to these electronic records where we are asked to provide a specific diagnosis code. Ultimately, the doctor or the provider is the one who is responsible for the code. We have to do it at the time of the note signing,” Church says.

January introduced new split/shared services documentation and billing challenges for Medicare providers in hospitals and skilled nursing facilities (SNFs). The new regulations, rolled out by the Centers for Medicare and Medicaid Services (CMS) as part of the 2024 Medicare Physician Fee Schedule (MPFS) final rule, took effect on January 1, 2024, and finalized CMS’s definition of the “substantive portion” of a split/shared visit (first introduced in 2022).

That definition – more than half of the total time spent by the physician or nonphysician practitioner performing the split or shared evaluation and management (E/M) services or a substantive part of the medical decision-making (MDM) – is crucial in 2024 for determining who will bill Medicare for such visits. It was developed in response to public comments asking CMS to allow either time or MDM to serve as the substantive portion of a split or shared visit.

For the first time in a decade, the Centers for Medicare and Medicaid Services (CMS) has overhauled its hierarchical condition categories (HCC), upgrading the underlying methodology to align with ICD-10-CM – which the rest of the healthcare system has been using since 2015. As a result, HCC version 28 requires greater specificity in documentation and code assignment to ensure accurate risk adjustment.

Matt Bridge continues his three-part series on how to achieve a high-performing revenue cycle for your facility. Bridge reports that you need an understanding as to where your organization falls on the RCM Maturity Framework. Here is Part Three in this exclusive series for ICD10monitor.

The journey toward fully mature revenue cycle management (RCM) is typically a five-step process that starts with evaluating the maturity of the current state of operations to determine where the organization falls on the RCM Maturity Framework, outlined in the first two articles of this three-part series. This is followed by the establishment of a realistic long-term maturity target, followed by the development of iterative annual goals to achieve it.

Matt Bridge continues his three-part series on how to achieve a high-performing revenue cycle for your facility. Bridge reports that you need an understanding as to where your organization falls on the RCM Maturity Framework. Here is Part Two in this exclusive series for ICD10monitor.

The RCM Maturity Framework, introduced in the first edition of this three-part series, is a powerful diagnostic tool in the quest to optimize and digitally transform revenue cycle performance. It serves as the basis for a practical approach to transforming revenue cycle management (RCM) to help future-proof operations through a hybrid model of in-house management, global services, advanced technologies, and actionable analytics.

Four stages make up the Maturity Framework: Emerging, Foundational, Advanced, and High-Performing. Where an organization falls within those stages is determined by its level of maturity across three pillars: service delivery, technology and interoperability, and analytics.

EDITOR’S NOTE: Medicare’s legacy quality reporting programs were consolidated and streamlined into the Merit-Based Incentive Payment System, known as “MIPS.”

The Merit-Based Incentive Payment System (MIPS) uses a composite performance score to determine if eligible physicians will receive a payment bonus, a payment penalty, or no payment adjustments.

If a physician bills more than $90,000 for Part B-covered professional services and they see more than 200 Part B patients, and has provided more than 200 covered professional services to those patients, the physician must participate in the MIPS program. It’s essential for all eligible clinicians to report in order to prevent a 9-percent downward adjustment for all Medicare Part B claims paid two years from the reporting year.

Matt Bridge begins a three-part series on how to achieve a high-performing revenue cycle for your facility. Bridge reports that you need an understanding as to where your organization falls on the RCM Maturity Framework. Here is Part One in this exclusive series for ICD10monitor.

Though healthcare organizations were expecting 2023 to end on a modestly high note, with many telling Kaufman Hallthat they expected to finally hit the 3 to 4-percent operating margins needed to help ensure long-term sustainability, the pressure is nonetheless on to hasten their rebound from 2022 margins that were 39 percent lower than 2021.

In response, finance leaders are seeking ways to accelerate cash flow, reduce expenses, and increase profitability, with many turning to global resources and technology to transform their revenue cycle management (RCM) operations.

February 07, 2024 - The 2024 Best in KLAS Software & Services report has recognized EHR vendor Epic as the top overall software suite, marking the fourteenth consecutive year that the company has earned the award.

The 2024 Best in KLAS report leverages information obtained from more than 26,000 evaluations representing the opinions of healthcare professionals from over 5,000 healthcare organizations.

Used by the Centers for Medicare and Medicaid Services (CMS) and commercial payors to forecast medical costs for patients with more complex healthcare needs, the HCC risk adjustment model measures relative risk due to health status to determine reimbursement levels. The more complex the patient's medical needs, the higher the provider's payment.

HCCs are now the preferred method of risk adjustment for the Medicare population which, according to figures from CMS, includes nearly 60 million people on both Part A and Part B, approximately 30.2 million of whom are enrolled in a Medicare Advantage (MA) plan. Thus, doing it correctly is crucial to Medicare providers and payors who wish to be appropriately reimbursed for the care provided to patients and beneficiaries.

BC Advantage»

What would happen if you had a medical emergency? Would the emergency room doctors know what medications you are taking? Would they know about your allergies? Would they know about your pre-existing conditions that might skew your blood work? Would they know who your emergency contact is? And would that emergency contact know all your important medical information to give to the emergency department staff?

Those questions kept Austinite Jennifer Devening looking for easy answers.

Austin American-Statesman»

Safeguarding revenues in the coming year requires healthcare systems to proactively navigate an evolving landscape with cross-functional collaboration, technological innovation, and increased AI investments. Additionally, going into 2024 operational excellence is the table stakes for healthcare organizations to improve bottom lines, and where AI and automation can provide a boost in productivity and costs.

Those are the high-level findings of MDaudit’s 2023 Benchmark Report on the trends, challenges, and opportunities encountered by U.S. healthcare organizations, which analyzes auditing, charge analysis, and denial assessment data from MDaudit’s network of more than 650,000 providers and 2,200 facilities. Insights are also from auditing professional and hospital claims totaling more than $5 billion and denials from commercial and government payors exceeding $150 billion.

Autonomous coding is an AI-driven leap forward from traditional Computer-Assisted Coding (CAC) systems, promising transformation for labor-intensive and error-prone coding processes in healthcare, with substantial benefits in terms of cost savings, efficiency, and reduced denials. However, to optimize its value and protect investments in coding solutions, healthcare organizations must understand the realities and limitations of this evolving technology.

Last week, the Medical Group Management Association (MGMA) suggested that federal regulators use corrective action plans and education to remedy information-blocking allegations instead of significant financial penalties. Now other stakeholders, including the EHR Association and Civitas Networks for Health, have weighed in with their concerns and suggestions for improving the final rule. 

Information blocking is when a provider knowingly and unreasonably interferes with the access, exchange, or use of electronic health information except as required by law or covered by a regulatory exception.

More organizations are releasing their comments to the Office of the National Coordinator for Health Information Technology, Centers for Medicare & Medicaid Services and Office of the Inspector General on the proposed federal rule to establish disincentives for information blocking by providers under the 21st Century Cures Act.

Most of the disincentives are aimed at providers participating in CMS programs, which some organizations like the American College of Radiology say is the appropriate mechanism for provider disincentives.