Client News Coverage

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.

The HIMSS EHR Association this week sent a letter asking the Centers for Medicare and Medicaid Services to extend the comment period on its Advancing Interoperability and Improving Prior Authorization Processes proposed rule by at least 45 days.

Health tech companies are in a tizzy: After years of letting companies roll out software tools to guide patient care with little oversight, the Food and Drug Administration is taking a tougher stance.

In September, the FDA announced its intentions to regulate many of these AI-powered clinical decision support (CDS) tools as devices — which regulators say has always been their plan and within their purview. But the industry says it was blindsided by the move. In a fierce rebuttal, the Clinical Decision Support Coalition filed a petition earlier this month asking the FDA to withdraw the final CDS guidance, arguing regulators are overstepping their bounds by trying to police medical practice. They also claim the FDA’s move violates the 21st Century Cures Act, a 2016 law that says tools that “provide limited clinical decision support” don’t count as medical devices.

FutureRx (FRx) announced today the launch of its first-of-a-kind healthcare platform for health plans and pharmacy benefits managers (PBMs) that combines modular technology solutions and, if needed, seamless access to pre-vetted fully integrated service providers on a single platform. FRx is a cloud-based, modular, user-configurable technology platform that was built from the ground up to meet complex and continuously evolving compliance requirements in today’s Medicare and Medicaid environment. As such, it is 100% compliant with government-sponsored regulations out of the box.

Once on the platform, health plan and PBM users can select from a full range of technology modules – including Rx Prior Authorization, Appeals/Grievances, Part D Stars, Drug Management Programs (DMP) and more – that are preconfigured out of the box with workflow and letters, and fully integrated with SureScripts and CoverMyMeds, as well as fax, phone, email, and mail capabilities that eliminate costly and time-consuming implementations.

Efforts to identify the right path forward for healthcare’s patient matching problem are gaining a foothold as stakeholders from across the spectrum come together to remove obstacles and implement effective solutions. Most notably, in 2022, efforts by industry organizations like Patient ID Now led to the temporary removal of Section 510 from the U.S. House and Senate Labor, Health and Human Services, Education, and Related Agencies (Labor-HHS) appropriations bills. While it was ultimately reinserted in the final version, its initial removal by the Senate was the first time that chamber had done so in 20 years – a significant achievement in the fight to eliminate the outdated rider barring funding of research into a national patient identifier.

Meanwhile, the Office for the National Coordinator (ONC) through its Project US@ collaboration with standards development organizations and other stakeholders issued the

A healthy, stable revenue cycle is crucial to every healthcare organization’s success. However, managing the revenue cycle takes experienced coders, complete documentation, and timely resolution of denials.

Administrative processes account for about 30% of U.S. healthcare costs, which means that all areas of a patient encounter, from check-in to billing and claims, are potential targets to obtain greater efficiency.

In its comments to the ONC on the draft QHIN, Participant and Subparticipant Additional Requirements SOP, the EHR Association recommends workforce authentication requirements be applied only to the Qualified Health Information Network workforce, with specific consideration given to participants and sub-participants who are not HIPAA-covered entities.

WHY IT MATTERS

The Office of the National Coordinator for Health Information Technology (ONC) is accepting comments on proposed requirements for QHINs, participants and sub-participants under its Trusted Exchange Framework and Common Agreement developed by the enlisted Sequoia project.

Industry groups and watchers have wide respect for the accomplishments over the past two decades of the Office of the National Coordinator for Health Information Technology.

Despite concerns about achieving interoperability across the industry and sometimes overly optimistic expectations about the industry’s ability to manage change, there’s widespread appreciation for the amount of change accomplished by the federal office.

The Office of the National Coordinator for Health Information Technology (ONC) has grown in its understanding, over time, about the breadth of technical capabilities and maturity of organizations that must implement regulations and technical requirements to achieve national goals.

This is not an easy process and ONC has shown a willingness to be open and learn about infrastructure capabilities across the healthcare ecosystem. This is particularly true in the pursuit of national interoperability, where a variety of health information technology (HIT) will be involved in the management and dissemination of all electronic health information.

Data governance was one of the major trends that shaped analytics in 2022.

Data governance isn't glamorous like augmented intelligence, machine learning or natural language processing. It's the grunt work of analytics.

But after many organizations suddenly realized the importance of data-informed decision-making at the start of the COVID-19 pandemic -- and have continued to recognize its value as world events like the war in Ukraine and repeated supply chain disruptions have resulted in ongoing economic uncertainty -- data governance is starting to be a critical need.

Leaders from EHR vendors such as Oracle Cerner and Meditech were named to the Electronic Health Record Association's executive committee for 2023.

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