Category: Industry News

The healthcare industry has been thrown a curveball with the introduction of the Coronavirus Disease 2019 (COVID-19). Becoming one of the biggest threats to the global economy and financial markets, the monetary impact remains unknown – both on the provider and patient side. HFMA Policy Director, Chad Mulvany, spoke out to provide guidance on the four things health systems should be doing now to keep coronavirus patients satisfied with their experience after they return home.

Get familiar with payer policy exceptions for coronavirus. 

America’s Health Insurance Plans has compiled a list of what some health plans are doing. Many are waiving copays for testing and covering telehealth services. Furthermore, the IRS has said that high-deductible health plans (HDHPs) can pay for testing and treatment without losing their HDHP status. Knowing what payers are doing will make for a more seamless billing experience for the patient, Mulvany said.

Rethink the organization’s financial assistance policies.

Many patients are losing work due to closures and restrictions resulting from the coronavirus and won’t be able to pay a bill that may not have been a problem a few months ago. It might make sense to extend assistance to people who wouldn’t otherwise qualify, Mulvany said. “I don’t know if it’s reasonable to do, but it’s a conversation to have,” he said.

Screen patients for financial assistance.

Be sure to communicate all applicable policies and practices for medical account debt resolution and provide financial assistance and/or charity options, if applicable.

Stay current with coronavirus coverage.

The Centers for Disease Control and Prevention has a wealth of information and resources on their website that is updated frequently.

With the uncertainty the coronavirus brings, Quadax understands researching new revenue cycle management solutions or vendors is most likely not a high priority on your list. But, please know, we are committed to serving and helping our clients’ billing processes. We hope you all stay happy and healthy!

Ken Magness is a focused healthcare professional with more than a decade of experience in helping clients understand the true value of automation in the revenue cycle management process. As the Strategic Initiatives Leader at Quadax, Ken and his team are passionate about connecting with healthcare providers to help them create and leverage the appropriate technology solutions to optimize the revenue cycle process and improve the experience of their patients and staff.

 

We just returned from the MGMA Financial Conference in Nashville and one of the hot topics was the shift in care settings. From the explosive growth of ambulatory surgery centers to the rise of in-home care, it’s clear we are in a period of extreme disruption in the healthcare industry. One of the biggest questions providers seemed to have at the conference was how they and their practices were going to be affected. We sponsored an educational session and were proud to have Thomas Campanella provide his experienced insights to the folks attending the conference.

Tom started the Q&A discussion defining disruption in healthcare as external factors that impact the status quo. He emphasized that we, as a society, cannot continue down this path of escalating healthcare costs. Here are a few questions and topics of discussion from his presentation:

Is there a particular stakeholder who is especially vulnerable to this disruption?

Hospitals are especially vulnerable because they’ve historically played a major role in the status quo “sick system” of healthcare. Their vulnerability increases because of their high fixed costs (e.g., infrastructure, technology, personal) and with the decrease in inpatient admissions and the growth in outpatient and care in the home setting, they become especially vulnerable to local, regional and national competitors, especially in this new age of transparency.

 

What are the causes of disruption in healthcare?

 

Active purchasers of healthcare services

The transition from passive to active purchasers in the following areas:

• Traditional Medicare to Medicare Advantage
• Traditional Medicaid to Medicaid Managed Care/PACE
• Fully-insured employers to self-insured employers
• Aggressively evolving commercial insurance companies
• Consumers with minimal out-of-pocket to HSAs

All of these shifts in how services are paid are leading to more transparency and more informed consumers who are demanding value-based care.

National & state health policies and regulations

The Affordable Care Act had a tremendous effect on the healthcare industry. Medicare and Medicaid policies and regulations are always evolving and as consumers are demanding more transparency, state and federal policy initiatives are being brought forth.

Socio-demographic changes

An increased focus on removing the barriers of social determinants of health to improve access to care combined with the aging baby boomer population and longer life expectancy, are disrupting the status quo by creating a major shift in care settings.

Advances in technology, science and discovery

These advances have allowed care that was previously only provided in a hospital setting to be provided in home. Innovations in healthcare has focused investments on giving people better access to primary care through offerings like telehealth.

Health IT is poised for explosive growth in areas like analytics, artificial intelligence, and mobile apps because it helps physicians deliver high-quality healthcare at a lower cost.

 

Which physician specialty is best positioned to be successful as a result of the disruption in healthcare?

When you hear the following terms, which specialty has the greatest impact on them?

• Managing risk
• Value-based health
• Population health
• Patient engagement
• Patient education
• Holistic
• Community engagement
• Social determinants of health

Primary care physicians will have the opportunity to take center stage as the trend of value-based care continues to climb.

Tom concluded his talk with some encouraging words. “This is the best time to be in healthcare,” he stressed. “During times of disruption, the organizations and employees that can make a difference will be rewarded tenfold.”

If you’re interested in the full discussion, you can listen to this webinar recording. We’d like to give MGMA a shout out for putting on a great event!

“The future of work and education is changing every day, and the best leaders are those who change with it. While efficiency was king in the Second and Third Industrial Revolutions, learning has taken center stage as we shift into the Fourth Industrial Revolution,” says Heather McGowan, who closed out MGMA20 | The Financial Conference Saturday in Nashville.

 

Ken Magness is a focused healthcare professional with more than a decade of experience in helping clients understand the true value of automation in the revenue cycle management process. As the Strategic Initiatives Leader at Quadax, Ken and his team are passionate about connecting with healthcare providers to help them create and leverage the appropriate technology solutions to optimize the revenue cycle process and improve the experience of their patients and staff.

The CAQH Index is a detailed report that addresses how reducing the burdens of administrative costs could reduce healthcare spending. The 49-page report is incredibly insightful and full of information, but in order to make it more digestible, we’ve pulled some statistics we found most valuable. All of the data in this post is directly from the CAQH report and the full report is available on their website through the link at the bottom of this blog.

The Current State of Administrative Costs

The healthcare industry spends an estimated $350 billion annually on administrative costs – due to its complexity. Of these costs, $40.6 billion is associated with transactions that are tracked by the CAQH Index. The Index states that $13.3 billion or 33% of those tracked costs could be saved by completing the transition from manual and partially electronic processing to fully electronic processing.

The Administrative Process

*Figure 1. Source: 2019 CAQH Index

The medical industry could save as much as $42.45 (including $29.27 for providers and $13.18 for plans) for a single patient encounter by requiring all eight of the transactions tracked to use a fully electronic workflow.

The greatest per transaction savings from moving from manual to fully automated can be realized in the following areas:

• Prior authorization ($12.31)
• Claim status inquiry ($7.72)
• Eligibility and benefit verification ($7.55)

Eligibility and Benefit Verification

Eligibility and Benefit Verification transactions represent the highest annual spending and savings opportunity. This is due to the large overall volume of this transaction and the volume conducted through partially electronic web portals.  This transaction accounts for 47% of the total medical industry spend. Providers have indicated that complicated benefits have resulted in additional points of contact with plans, and providers check on eligibility and benefit information multiple times throughout an encounter.

The medical industry could save 85 cents per transaction by conducting eligibility and benefit verification electronically using the HIPAA standard as opposed to a web portal. In addition, medical providers could save 8 minutes per transaction by switching to fully electronic processing – adding even more savings.

Prior Authorization

Prior Authorization is the costliest and most time consuming to conduct manually. Industry adoption of electronic prior authorization is lower than other transactions due to provider awareness, vendor support, inconsistent use of data content allowed in the standard, state laws mandating manual processes, and lack of an attachment standard to support the exchange of medical documentation.

Moving from web portals to fully electronic could save $2.11 and 17 minutes per transaction, as the time is slashed from 21 minutes to four.

Claim Submission

Claim submission continues to have the highest electronic adoption rate, which is critical to sustain in order to control costs. The rate of fully electronic processes has remained steady at 96% compared to the prior report. Even though this transaction is mostly automated, there is still $635 million in savings opportunity through complete automation.

Electronic Attachments

Serving as a bridge between clinical and administrative data, attachments are critical to the success of value-based payment models. As we transition from fee-for-service to value-based payment, there is a clear need for clinical and administrative systems to streamline the exchange of information to support patients, providers and plans.

Although attachments are primarily exchanged through costly and time consuming manual methods, the volume of these transactions is low, accounting for less than one percent of the total volume of administrative transactions. An average of $4.50 and 11 minutes of staff time is spent on each manually processed attachment.

Coordination of Benefits

Adoption of electronic coordination of benefits has the second highest adoption rate and the fastest growth among the transactions. The spend associated with this transaction is the lowest among the medical industry administrative transactions reported. Medical plans could save an additional $16 million by switching their remaining manual COB transactions to electronic.

Claim Status Inquiry

Claim status volume decreased for the second year in a row. This is partially because providers now only check on the status of a claim after a minimum of 30 days versus more frequently, which may be due to quicker adjudications and payments from plans.

This transaction accounts for 15% of medical spend and is the second most expensive transaction to conduct manually ($10.13) and electronically ($2.41). On average, it takes 12 minutes to conduct a manual claim status inquiry and only four minutes for electronic.

Claim Payment

The volume of claim payments rose 18%, however, claim submission volume is higher because payments are often made in bulk where one payment is associated with multiple claims.

Paper checks, on average, take five minutes to process compared to three minutes electronically. By conducting claim payments electronically, the medical industry could save $135 million annually.

Remittance Advice

The adoption of electronic remittance advice (ERA) transactions increased slightly from the last report. Roughly 20% of the total spent on administrative transactions is around remittance advice.

On average, medical providers reported that an ERA required two minutes of staff time compared to seven minutes when conducting the transaction manually.

The Industry Call to Action

To support adoption of fully electronic transactions that can accommodate evolving market needs, limit cost and reduce burden, CAQH proposes the following actions for the industry to help maintain and improve upon the achievements accomplished to date:

1. Focus efforts to reduce provider burden
2. Accelerate standards and operating rule development to support the harmonization of administrative clinical data exchange
3. Need for vendor adoption of all standards and operating rules
4. Expand research related to the administrative workflow

For more information about the CAQH Index, please visit www.CAQH.org. You can download the full CAQH report here. Quadax can help your organization automate any of these transactions, whether you’re a hospital, laboratory or physician practice. Let’s talk!

Ken Magness is a focused healthcare professional with more than a decade of experience in helping clients understand the true value of automation in the revenue cycle management process. As the Strategic Initiatives Leader at Quadax, Ken and his team are passionate about connecting with healthcare providers to help them create and leverage the appropriate technology solutions to optimize the revenue cycle process and improve the experience of their patients and staff.

 

Administrative overhead is a real burden for many providers. Technology and automation have been mandated by the Centers for Medicare and Medicaid in certain parts of healthcare processes, but overall, the healthcare industry is way behind in utilizing technology and automation for increased efficiencies and profit. This blog will explore the latest findings from the Council for Affordable Quality Healthcare, Inc. (CAQH) as well as some of the potential reasons providers don’t pursue automation, despite its proven benefits.

The seventh annual report from CAQH found that prior authorization costs are the most costly, time-consuming transaction for providers. On average, providers spend almost $11 on each manual prior authorization, which is up from $6.61 just a year ago. Obviously, the costs are significantly lower for partially and fully electronic transactions, at $4 and $2 respectively, but automation of prior authorization transactions remained very low in 2019.

Why is it so difficult? Unfortunately, there are several reasons:

1. Data inconsistency

Payers don’t use the same codes to communicate prior authorization status, errors and next steps, including the need for clinical documentation to prove medical necessity. Standardization and transparency is needed to make the process easier for all involved.

2. No standardized clinical documentation

Health plans require different levels of clinical documentation detail for prior authorization requests to help determine medical necessity and appropriateness. This lack of standardization makes it difficult to automate a prior authorization response.

3.  Lack of clinical and administrative system integration

Bi-directional integrations between practice management systems and clinical systems, like electronic health records, are uncommon, which means data has to be manually entered into one system from another. This represents an opportunity for human error and a drain on productivity and efficiency.

Despite the known barriers, not much progress is being made year over year. The CAQH found that adoption of prior authorizations increased by only one percent from 2018 to 2019 to 13% overall. However, the CAQH just approved a 2-day rule to accelerate the prior authorization process, and 80% of industry stakeholders are in agreement.

The rule outlines the following timelines must be met 90% of the time within a calendar month:

• A two-day additional information request. A health plan, payer or its agent has two business days to review a prior authorization request from a provider and respond with the additional documentation needed to complete the request.
• A two-day final determination. Once a health plan receives all requested information from a provider, its payer or agent has two business days to send a response containing a final determination.
• Optional close out. A health plan may choose to close out a prior authorization request if it does not receive the additional information needed to make a final determination from the provider within 15 business days of communicating what additional information is needed.

This new rule is very encouraging, considering the health plans participating in the CAQH represent 75% of the insured population in the United States. This rule will not only help reduce administrative costs for providers, but more importantly, it will help save lives by ending delays in care caused by prior authorization requirements.

If you’re interested in reading about best practices for mitigating prior authorization challenges, check out this whitepaper.

The top 5 challenges facing healthcare today can all be mitigated by a healthier revenue cycle. This blog will explore changes you can make in your rev cycle to address and even conquer these challenges, outlined by Managed Healthcare Executive.

Challenge #1: Costs & Transparency

It’s a bit shocking that we’re going into 2020 with so many offices not being able to accurately confirm a patient’s eligibility or provide an accurate out-of-pocket amount that will be owed for the service provided. If your team struggles with providing this information, there are tools you can easily implement to remove these challenges.

The right patient access solution (as part of a revenue cycle management platform) can help you reduce denials due to avoidable pre-service errors, which typically account for 50% of denials, in addition to:

• Increase revenue from payer and patient payments
• Spend less time tracking down patient information
• Increase staff productivity
• Reduce bad debt and avoidable write-offs

Challenge #2: Consumer Experience

Most Americans aren’t able to correctly define copay, deductible and premium. These same folks typically will avoid going to the doctor for recommended or even required services because they’re afraid of the cost and confused by the overall experience. After all, healthcare is the #1 cause of bankruptcies in the United States, so the fear is legitimate.*

It shouldn’t be unreasonable for a patient to know what to expect throughout their entire experience of receiving care. A strong revenue cycle management solution should be able to help you:

Identify –

• Patient’s coverage and benefit verification
• Patient’s financial responsibility
• Patient’s need for financial assistance vs. ability to pay

Communicate –

• The patient’s insurance coverage for service
• Set payment expectations (how much to pay now and methods of payment)

Collect –

• The amount the patient owes at the time of service

Providing this information to your patients not only ensures a positive experience for them, it relieves a huge burden from your staff by not having to deal with frustrated and confused patients. This resource guide can help you explain common healthcare terms to your patients. We encourage you to print it and make it available to your patients.

Challenge #3: Delivery System Transformation

Being able to provide care to those that don’t have easy access is a growing challenge.

Critical Access Hospitals (CAH), designated by the Centers for Medicare and Medicaid Services, are designed to reduce the financial vulnerability of rural hospitals and improve access to healthcare by keeping essential services in rural communities. Because of the immense financial constraints CAHs face, resources can’t afford to be wasted. Optimizing efficiencies within their revenue cycle provides a significant opportunity to reduce operating costs and improve productivity. These facilities should be required to use technology to optimize their revenue cycles so staff isn’t wasting time on activities that could be easily automated.

Challenge #4: Data & Analytics

Just having access to data isn’t enough. Revenue cycle teams need actionable data – they need to be able to make necessary changes and improvements based on the data they have. It’s great if you know what percentage of claims are being denied, but do you know why they’re being denied? Are there certain providers that are denying claims at a higher rate? Is there a specific procedure code that’s being denied more than any other?

Actionable data helps you:

• Gain insight into your data to inform your decisions regarding resource allocation, process improvement, and strategic rev cycle management.
• Access your rev cycle activity from disparate systems to identify contributing factors and investigate cause-effect relationships affecting claim denials and appeals.
• Monitor changes over time and anticipated reimbursement of claim denials, and identify root cause by payer, denial category, denial reason, CPT and more.

Challenge #5: Data Interoperability

Accessing data between disparate systems is a common challenge in healthcare. We’ve talked with large healthcare systems that are looking to consolidate their vendors, even if that means foregoing unique functionality that a specific vendor provides, in order to eliminate data silos.

The right revenue cycle solution should be able to feed data into your EHR and other critical systems so you can access your data wherever and whenever you need it. And the solution should be comprehensive enough to allow you to manage your entire revenue cycle process without needing additional vendors to supplement missing functionality.

The Bottom Line

Money makes the world go round. The revenue cycle is the lifeblood of a healthcare organization. If managed at it’s highest efficiency, your organization will reap the benefits of maximum reimbursements and staff productivity – with streamlined resources.

Ken Magness is a focused healthcare professional with more than a decade of experience in helping clients understand the true value of automation in the revenue cycle management process. As the Strategic Initiatives Leader at Quadax, Ken and his team are passionate about connecting with healthcare providers to help them create and leverage the appropriate technology solutions to optimize the revenue cycle process and improve the experience of their patients and staff.

Source:
*CNBC Medical Bills Are the Biggest Cause of US Bankruptcies: Study, Dan Mangan June 2013

With all of the attention on healthcare transparency, it seems ironic that Americans are more and more confused about healthcare, specifically their insurance policies. Continue reading “Healthcare Providers Must Educate on Patient Financial Responsibility”