Client News Coverage

The payer/provider relationship is often seen as adversarial, with delays and denials by insurerstaking the blame for falling hospital revenues. But these supposed antagonists are closer than they would initially appear.

For providers, the goal of revenue integrity is to take great care of patients, maximize the reimbursement to which they’re legitimately entitled, create operational efficiencies, and maintain regulatory compliance. Contrast that with payment integrity on the payer side, the goals of which include enabling a great beneficiary experience, member retention, payment accuracy, operational efficiencies, and maintaining compliance.

Revenue cycle management (RCM) has never been more important to the success of healthcare providers across the care spectrum, but the industry faces myriad challenges. A continuing labor shortage and lack of skilled workers threaten revenues at a time when hospital operating margins hover near zero.

While highly skilled professionals are still needed, RCM teams can work smarter and not harder by using technology to automate manual processes and deploy advanced analytics to identify the cause of denials. Further, as private insurers follow Medicare’s lead by increasing third-party audits, providers need to understand their claims and auditing process at a foundational level to support their billing practices and maximize legitimate revenue.

During a virtual media briefing this week, the HIMSS Electronic Health Record Association outlined some of the comments it plans to send the Office of the National Coordinator for Health IT about its draft Health Data, Technology and Interoperability: Certification Program Updates, Algorithm Transparency and Information Sharing proposed rule, or HTI-1.

While some of the rule's details are still being parsed, EHRA said it has reservations about the ability of its member IT companies to balance new regulatory compliance with other HHS requirements – and has questions about a lack of provider incentives, information blocking rule challenges and more.

When the federal Public Health Emergency (PHE) ended on May 11, many of the waivers that kept external audits in check also vanished. As a result, healthcare organizations are bracing for an influx of demand letters, claim changes, and heightened regulatory and billing practice scrutiny by Recovery Audit Contractors (RACs), Medicare Administrative Contractors (MACs), Supplemental Medical Review Contractors (SMRCs), Unified Program Integrity Contractors (UPICs), Targeted Probe-and-Educate (TPEs), Comprehensive Error Rate Testing (CERT), and commercial payors.

The uptick in audit activity doesn’t have to leave provider organizations exposed, however. Proper planning and a well-designed external audit strategy can ensure a rapid, effective, and compliant response while mitigating future risk.

With revenue cycle (76%), clinical administration (55%), and finance (36%) among the top five areas benefiting most from automation and artificial intelligence (AI), it’s easy to see why 98% of health care leaders say their organizations have implemented or are planning to implement AI. That includes nearly 48% that have already taken the leap, according to Optum’s annual survey on AI in health care.

However, it makes no difference how large the investment or advanced the technology solution is if the patient data flowing through it lacks integrity. In other words, when it comes to AI and patient data, the adage “garbage in, garbage out” still applies. It’s also a very real problem, as evidenced by an average duplicate patient record rate that runs as high as 18% in the typical facility and patient misidentification issues that cost the health care industry more than $6 billion in denied claims.

Patrice Wolfe, MBA is CEO of AGS Health of Washington, DC.

When health systems are immersed in data related to billing, denials, internal audits, and external payer audits, it can be overwhelming to track, manage, and process what is an overwhelming amount of raw data. Creating a value-generating revenue integrity team and pairing it with technology is the answer to harnessing that data and using it to positively affect the tight margins experienced by many healthcare organizations.

While this might seem like a bold statement, the only way to productively use your data is to employ sophisticated analytics that will provide actionable insights on how to improve billing compliance and maximize revenues.

Nashville - AGS Health works with scores of hospitals providers on revenue cycle management and helping sure organizations get money more quickly, but the company is also working with organizations on health equity.

Cheryl Cruver, chief revenue officer of AGS Health, spoke about the growing interest in health equity in a conversation with Chief Healthcare Executive® at the ViVE Conference.

Revenue cycle management solutions leader AGS Health is pleased to launch operations in Manilla, Philippines. Serving as a strategic growth partner to more than 100 major healthcare providers across the U.S., the expansion will offer AGS Health and its customers increased access to global talent.

MDaudit, an award-winning provider of technologies and analytics tools that enable premier healthcare organizations to retain revenue and reduce risk, sees the retirement of its long-time president and CEO, Peter J. Butler, effective March 31, 2023. Stepping into the CEO role will be the company’s current COO, Ritesh Ramesh.

Butler will continue serving on MDaudit’s Board of Directors and as an investor, advising on future investments and growth opportunities for the company. He has been with MDaudit for 30 years, including the past 16 as president and CEO.

The Office of Inspector General (OIG) makes no secret about the investigative target it has placed on Medicare Advantage plans and the use of unsupported hierarchical condition category (HCC) assignments. Over the past 18 months, its investigations have netted clawbacks as high as $54.3 million from SCAN Health Plan.

Nor are health plans the only ones at risk when it comes to high-risk codes. While payers may be the ones writing the checks for improper reimbursements, the providers who submitted the claims are being targeted with audits that will inevitably result in repayments to the health plan.

Healthcare organizations undoubtedly felt a sense of relief as 2022 faded in the distance, taking with it a devastating financial performance that resulted in negative profit margins for more than half of U.S. hospitals – the worst year hospitals have faced since the start of the pandemic, according to Kaufman Hall. Not only were operating margins down for most of 2022, but hospitals also struggled with higher labor costs in a more competitive market plagued by chronic clinical and administrative skill shortages.

Physician practices fared no better, with 90% saying that soaring expenses outpaced revenues last year, according to a survey by the Medical Group Management Association. Staffing and labor costs were cited most often as the source of rising costs. Other common culprits were lower reimbursement rates, significant increases in lab supply and drug costs, higher utility costs, lower patient volumes, and rising malpractice premiums.

On March 13, the HIMSS EHR Association submitted its comments to the Centers for Medicare and Medicaid Services on its Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule.

Over the years, computer-assisted coding (CAC) has proven its ability to boost revenue team productivity and accelerate critical decision-making while reducing denials, missed charges, and low-risk scores. CAC also increases coder productivity and code capture, and enables flexible and scalable coding to increase accuracy, efficiency, productivity, and flexibility.

Indeed, these benefits are why we are seeing a rapid uptick in adoption of CAC on the professional side of the healthcare house. Once reserved primarily for facility-based coding, today’s CAC solutions are stepping up to fill the void created by the chronic coder shortage that is impacting both facility and professional fee coding while helping to maximize the performance of any healthcare organization’s coding operations with improved throughput and quality – increasing coder productivity by 25%-45% and decreasing Discharged Not Finally Coded (DNFC) by between one and three days.

Revenue cycle management company AGS Health opened an office in Manila, Philippines.

AGS said in a March 7 news release the expansion will support end-to-end accounts receivable services.