Client News Coverage

Improper documentation and coding are driving outpatient reimbursement inefficiencies that cost the US healthcare system approximately $54 billion annually. Left unaddressed, these costs will continue increasing in tandem with outpatient revenue, which is growing at a year-over-year rate of 9 percent as consumerism and federal mandates converge to divert care away from the inpatient environment.

For providers, primary catalysts for change are: 1) the evolving regulatory environment, which includes the ongoing transition to value-based care and reimbursement restrictions such as Medicare’s Two-Midnight Rule; and 2) the expansion in the types of procedures available on an outpatient basis. For patients, escalating healthcare costs at a time when their share of the financial burden is also rising, coupled with the convenience of outpatient care, are pushing them away from hospital settings.

Industry leaders want to see more flexibility and clarity from the US Food and Drug Administration (FDA) as it seeks to finalize guidance on the use real-world data (RWD) from electronic health records (EHRs) and medical claims to support regulatory decision-making.

The comments were in response to the FDA’s draft guidance “Assessing Electronic Health Records and Medical Claims Data to Support Regulatory Decision-Making for Drug and Biological Products,” which was issued in September 2021 (RELATED: FDA issues draft guidance on RWD sourced from EHRs, claims data, Regulatory Focus 29 September 2021). The comment period closed on 24 January 2022.

A recent report from the HHS Office of the Inspector General (OIG) turned heads across the healthcare industry after pointing to a notable rise in inpatient hospital stays where upcoding was believed to be the culprit. Compliance professionals who have been in the healthcare industry any length of time know what’s next: targeted billing reviews by the Centers for Medicare and Medicaid Services (CMS) around hospital stays that are vulnerable to upcoding.

More specifically, the OIG analysis from FY14-FY19 found that hospitals are “increasingly billing for inpatient stays at the highest severity level, which is the most expensive one,” and that inpatient stays accompanied by a significant medical condition—representing the highest cost stays—grew by 20%. In contrast with high severity growth, medium- and low- severity inpatient stays dropped by 22% and 12% respectively. Based on the findings, one analysis suggests that kidney and urinary tract infections, pneumonia and renal failure were conditions likely to have a classification as high severity.

A report issued in early 2021 by the US Department of Health and Human Services (HHS) Office of the Inspector General (OIG) raised a number of red flags that should be informing hospital and health system audit strategy for the foreseeable future. Covering fiscal year (FY) 2014 through FY2019, the OIG analysis points to a notable rise in costly inpatient hospital stays—many coded at the highest severity level.

The report, which cautioned its findings were based only on an analysis of claims data and not the medical record review necessary to determine appropriateness, found that the number of stays at the highest severity level increased almost 20 percent during the time frame examined and decreased for each of the other severity levels.

As we face the third year of the global pandemic, hospitals and health systems are desperate to shore up bottom lines that have been battered by ongoing financial losses projected to exceed $100 billion in 2021. The key to undoing some of the financial damage is optimizing revenue flow and reducing compliance risk, which requires an understanding of the exact driving forces behind the devastating losses.

For many healthcare organizations, the primary problem can be traced to bundling errors, COVID-19 claim denials, and a range of coding issues.

That’s according to Hayes’ inaugural auditing and revenue integrity report, Healthcare Auditing and Revenue Integrity: 2021 Benchmarking and Trends Report, which analyzed more than $100 billion worth of denials and $2.5 billion in audited claims. It found that bundling errors were the top culprit behind the 34% of inpatient hospital charge initially denied in 2021, each with an average value of $5,300. Internal auditors also identified a significant number of concerns centered around disagreements between procedure codes and diagnoses, contributing to 33% of all internal audits containing “disagree” findings.

As the Omicron variant spreads across the US and the delta variant continues to push COVID-19 cases higher, it’s a grim reminder that the COVID-19 pandemic is far from over. Although 60% of the country is vaccinated with multiple doses and many lessons were learned by the 2020 pandemic cycle, hospitals and health systems are preparing for a rough road ahead. They are bracing for higher utilization, staffing shortfalls, and an increase in demand for COVID-related services leading to an increase in the clinical and financial pressure in days and months ahead.

Since the advent of the pandemic in 2020, healthcare organizations are trying to mitigate compliance and revenue risks. We will continue to provide data-driven insights to healthcare organizations during and after the pandemic.

An exclusive Tech Tribune Q&A with Brad Bostic (co-founder, chairman, and CEO) of hc1, which was honored in our:

  2022 Best Tech Startups in Indianapolis

  2021 Best Tech Startups in Indiana

  2021 Best Tech Startups in Indianapolis

  2020 Best Tech Startups in Indiana

  2020 Best Tech Startups in Indianapolis

The senior care industry has had to navigate tremendous challenges over the past year. From staffing shortages to the demands of the COVID-19 pandemic, 2021 hasn’t been easy. While advancements like the COVID-19 vaccines have brought some relief to those challenges, the senior care industry will face many more challenges as we move into 2022.

We reached out to experts in the senior care field to learn their predictions about the coming year.

Accelerated adoption of digital health and health information technology (health IT) is well into the process of transforming access to and delivery of healthcare in the U.S. and across the globe – and their power has been on full display throughout the unprecedented global COVID-19 pandemic. From telehealth and information exchange to artificial intelligence and machine learning, optimizing the reach and utilization of health IT has brought safe, quality care to previously underserved areas while creating new opportunities that promise to make a lasting impact on patients and providers alike.

While advancements have been made, interoperability and comprehensive standards to support health information exchange are works in progress, and uncertainty over compliance with new and evolving regulatory mandates – such as those governing handling of patient data in the 21st Century Cures Act – persists. The good news is that collaborations between health IT developers, provider and payer organizations, industry associations and state and federal agencies continue to evolve and improve.

November 03, 2021 - Providers are having a difficult time billing for services related to COVID-19, with 40 precent of charges for coronavirus-related care initially winding up as claim denials in the first 10 months of 2021, according to a recent analysis of more than $100 billion worth of denials and $2.5 billion in audited claims.

The analysis performed by healthcare technology company Hayes also found that 40 percent of professional outpatient audits for COVID-19 and 20 percent of hospital inpatient audits for COVID-19 failed.

The Senate’s recent decision to repeal the ban on funding for the development of a unique patient identifier (UPI) marks a potential watershed moment in the development of what previously has been a hot third rail for privacy concerns.

This controversial possibility of developing a UPI provides a new opportunity to link a patient’s health records throughout the health ecosystem, but also highlights the inherent challenges of such a project.

The Senate’s recent decision to repeal the ban on funding for the development of a unique patient identifier (UPI) marks a potential watershed moment in the development of what previously has been a hot third rail for privacy concerns.

This controversial possibility of developing a UPI provides a new opportunity to link a patient’s health records throughout the health ecosystem, but also highlights the inherent challenges of such a project.

Accelerated adoption of digital health and health information technology (health IT) is well into the process of transforming access to and delivery of healthcare in the U.S. and across the globe – and their power has been on full display throughout the unprecedented global COVID-19 pandemic. From telehealth and information exchange to artificial intelligence and machine learning, optimizing the reach and utilization of health IT has brought safe, quality care to previously underserved areas while creating new opportunities that promise to make a lasting impact on patients and providers alike.

While advancements have been made, interoperability and comprehensive standards to support health information exchange are works in progress, and uncertainty over compliance with new and evolving regulatory mandates – such as those governing handling of patient data in the 21st Century Cures Act – persists. The good news is that collaborations between health IT developers, provider and payer organizations, industry associations and state and federal agencies continue to evolve and improve.

Compliance has gotten a bad rap in healthcare. Traditionally viewed as a necessary cost center, this department is too often viewed as the police force of a health system.

A lot is missing from this simplistic view of the processes that ensure hospitals and health systems aren’t hit with avoidable penalties when the auditors come knocking. Within a rapidly evolving regulatory framework that includes more than a year of fluctuating COVID and telehealth guidance (among other changes), compliance in essence becomes the safeguard to a healthy, sustainable bottom line.

HISTalk»

As actors work to comply with the Cures Act Final Rule, it’s become clear that greater consensus is needed regarding the interpretation of the definition of electronic health information (EHI) and the designated record set (DRS). As many readers know, the Cures Act Final Rule includes interoperability requirements related to information blocking and health IT certification. Both rely on the definition of EHI, which is grounded in the definition of the DRS, as defined by HIPAA.

I’m proud my organization AHIMA has been able to collaborate with the American Medical Informatics Association (AMIA) and the Electronic Health Record Association (EHRA) on a taskforce to examine the relationship between specific aspects of the Cures Act Final Rule and the definitions of DRS and EHI.