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Feb. 4—The lead federal healthcare official pledged Monday to stop surprise medical bills—one of the few healthcare issues garnering bipartisan support in Congress.
Alex Azar, secretary of the U.S. Department of Health and Human Services, told attendees at the AcademyHealth annual meeting in Washington, D.C., that the administration has pledged “ending surprise bills.”
Azar’s promise followed a January roundtable—to which members of the healthcare industry were not invited—for select patients with President Donald Trump at the White House. Azar recounted some of the billing stories patients shared at the meeting.
“The president, like so many Americans who’ve heard these stories or had such an experience themselves, was shocked and outraged,” Azar said. “He’s committed to making fair, accurate, and transparent prices a key part of his healthcare agenda.”
However, industry watchers said the issue is most likely to be resolved by Congress because regulatory approaches would be unlikely to provide comprehensive solutions. The issue already has drawn unusual bipartisan pledges of action in Congress, and the administration’s commitment could give the effort greater momentum.
In the last Congress, legislative proposals included a bipartisan draft measure by Sen. Bill Cassidy (R-La.), a Democratic bill by Sen. Maggie Hassan (D-N.H.), and House versions by Reps. Lloyd Doggett (D-Texas) and Michelle Lujan Grisham (D-N.M.). The approaches of the bills vary in fundamental ways, and legislators are working on updated versions for the current Congress.
“Given that the issue of surprise bills is one of the few things that anyone in Congress can agree upon as being a bad thing that needs to stop, this to me is a bipartisan issue, and I would expect that both sides are probably looking to do something productive and consumer-centric,” said Chad Mulvany, FHFMA, director of healthcare finance policy, perspectives and analysis, for HFMA.
It remains unclear what specific approach Congress will use to protect consumers from unexpected healthcare bills, and providers and payers have urged starkly different federal requirements. However, a meeting of congressional staff last week with various industry representatives indicates legislators will advance bills to address the issue in the coming months, said Wade Symons, practice leader at the Regulatory Resource Group of Mercer.
The American Hospital Association (AHA) and the Federation of American Hospitals (FAH) wrote a letter to members of Congress in December, stating that any federal approach must prohibit balance billing and limit patients’ cost-sharing to an in-network amount.
“We appreciate that this is a high priority issue for Congress, as it is for us, and we intend to provide more specific feedback to policymakers early in the new Congress,” wrote Richard Pollack, president and CEO of AHA, and Charles Kahn, president and CEO of FAH.
For its part, America’s Health Insurance Plans (AHIP) has urged hospitals and other inpatient facilities to engage in “good-faith efforts” to ensure that their hospital-based physicians contract with the same health insurance providers as the hospital.
“This would go a long way to reduce and prevent consumers from receiving a big surprise balance bill,” AHIP wrote on its website.
Anders Gilberg, senior vice president, government affairs for the Medical Group Management Association (MGMA), raised concerns about any federal approach that would “force a physician into a contract with a health plan that has none of the protections of a contract” yet requires them to accept contracted rates.
“We could see this an easy way for health plans to manipulate the market to not have to contract with emergency physicians or anesthesiologists or radiologists; that has to be carefully balanced as well,” Gilberg said in an interview.
Even more concerning would be any proposal to force out-of-network physicians to accept some share of Medicare rates, which are typically far lower than commercial plan rates, Gilberg said.
AHIP recently launched a coalition with other insurer advocates, consumer groups, and business advocates committed to advancing policies that address surprise bills.
Physician advocates have begun to offer specific approaches. In January, the American College of Emergency Physicians (ACEP) released a framework of proposed approaches that included:
An increasing number of states have enacted laws focused on unexpected medical bills. As of December 2018, 25 states have laws offering some balance-billing protection to their residents, and nine of them offer “comprehensive protections,” according to a Commonwealth Fund analysis.
“I think something is going to happen [nationally], and I would look for it to look something like arbitration, like what New York is doing,” Mulvany said.
New York’s law went into effect in 2015 and includes:
“We love it because hospitals are not in the crossfire anymore,” said Jeffrey Gold, JD, senior vice president for the Healthcare Association of New York State (HANYS). “It has been very helpful in dealing with the issue by keeping patients out of the middle.”
Hospitals have been surprised by the unexpectedly small number of billing disputes between health plans and providers that have gone to the arbitration process under the law, Gold said in an interview.
New York’s independent medical claims database, which is used to define usual and customary costsfor local specialists, also drew praise from Gilberg as being “considerably more preferable than any kind of benchmark off of Medicare.”
In the meantime, the bipartisan Cassidy approach, which would bar balance billing and require insurers to pay clinicians 125 percent of usual and customary charges for out-of-network care, appears to remain viable in Congress, Symons said in an interview.
“That seems to be the type of thing that they are looking at,” Symons said.
Neither health plans or providers are likely to readily support that approach because it would pay providers less than they now can collect and require plan to cover a cost they do not now cover.
“You’re going to have to look at where is the middle ground, and I’m not sure that we’ve gotten there yet,” Symons said.
Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare
Publication Date: Tuesday, February 05, 2019
Two senior leaders at R1 talk about the advantages of working with an innovative revenue cycle partner that offers technology-enabled revenue cycle and patient experience services.
Two senior leaders at Grant Thornton talk about the advantages of robotic process automation to improve office efficiency, reduce costs, and mitigate risk.
A senior leader of VitalWare talks about the need to create a comprehensive pricing strategy for consumers and how to get started.
Two of HealthTrust’s senior leaders talk about strategies for optimizing the hospital workforce to improve productivity and reduce waste.
Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
Read how Gwinnett Medical Center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process.
Read how Orlando Health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce A/R days.
To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.
Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.
Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.
Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
Announcements from several commercial payers and the Centers for Medicare and Medicaid Services (CMS) early in 2015 around increased efforts to form value-based contracts with providers seemed to point to an impending rise in risk-based contracting. Rather than wait for disruption from the outside in, health care providers are now making inroads on collaborating with payers on various risk-based contracting models to increase the value of health care from within.
Yuma Regional Medical Center (YRMC) is a not-for-profit hospital serving a population of roughly 200,000 in Yuma and the surrounding communities. Before becoming a ZirMed client, Yuma was attempting to manually monitor hundreds of thousands of charges which led to significant charge capture leakage. Learn how Yuma & ZirMed worked together to address underlying collections issues at the front end, thus increasing Yuma’s overall bottom line.
Kindred Hospital Rehabilitation Services works with partners to audit the market and the facility’s role in that market to identify opportunities for improvement. This approach leads to successes; Kindred’s clinical rehab and management expertise complements our partners’ strengths. Every facility and challenge is unique, and requires a full objective analysis.
As the critical link between patient care and reimbursement, health information enables more complete and accurate revenue capture. This 5-Minute White Paper Briefing shares how to achieve cost-effective revenue integrity by your optimizing HIM systems.
Speedier cash flow starts with better CDI and coding. This 5-Minute White Paper Briefing explains how providers can improve vital measures of technical and business performance to accelerate cash flow.
Qualified coders are getting harder to come by, and even the most seasoned professional can struggle with the complexity of ICD-10. This 5-Minute White Paper Briefing explains how partnerships can help improve coding and other key RCM operations potentially at a cost savings.
The point of managing your revenue cycle isn’t just to improve revenue and cash flow. It’s to do those things effectively by consistently following best practices— while spending as little time, money, and energy on them as possible.
How Lucile Packard Children’s Hospital Stanford increased payments received within 45 days by 20% and reduced paper submission claims by 70% by using ZirMed solutions.
The reasons claims are denied are so varied that managing denials can feel like chasing a thousand different tails. This situation is not surprising given that a hypothetical denial rate of just 5 percent translates to tens of thousands of denied claims per year for large hospitals—where real‐world denial rates often range from 12 to 22 percent. Read about how predictive modeling can detect meaningful correlations across claims denials data.
Emergency Mobile Health Care (EMHC) was founded to be and remains an exclusively locally owned and operated emergency medical service organization; today EMHC serves a population of more than a million people in and around Memphis, answering 75,000 calls each year.
Since the Physician Quality Reporting Initiative (PQRI) introduction, CMS has paid more than $100 million in bonus payments to participants. However, these bonuses ended in 2015; providers who successfully meet the reporting requirements in 2016 will avoid the 2% negative payment adjustment in 2018, so now is the time to act! Included in this whitepaper are implications of increasing patient responsibility, collections best practices, and collections and internal control solutions.
Getting paid what your physician deserves—that’s the goal of every biller. Yet even for the best billers, achieving that success can be elusive when denials stand in the way of success, presenting challenges at every turn. Denials aren’t going away, but you can learn techniques to manage and even prevent them.Join practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC, to: Discover methods to translate denial data into business intelligence to improve your bottom line, determine staff productivity benchmarks for billers, and recognize common mistakes in denial management.
Physician practices must improve organizational efficiency to compete in this era of reduced reimbursement and escalating administrative costs.
Many healthcare organizations are pursuing next-generation health information systems solutions. Learn more about Navigant's work with University of Michigan Health System.
The proper implementation of healthcare information technology systems is crucial to an organization’s financial health.
As value-based payment models evolve, providers are challenged to maintain superior clinical outcomes while controlling costs.
Read more about factors contributing to the changes in the post-acute marketplace and what it means for manufacturers, physicians, clinicians, patients, and post-acute facilities as they anticipate the transition to the second curve.
HSG helped the physicians and executives of St. Claire Regional in Morehead, Kentucky, define their shared vision for how the group would evolve over the next decade. As well as, develop the strategic and operational priorities which refocused and accelerated the group’s evolution.
The client was a nine-hospital health system with 14 clinics serving communities in a multi-state market with very limited access to care, poor economic conditions, high unemployment, and a heavy Medicare/Medicaid/uninsured payer mix. In most of these communities, the system was the sole source of care. Though the clinics were of substantial size (they employed 98 physicians) and comprised of multiple specialists, the physicians functioned as individuals and the practices lacked any real group culture.
Clinical integration can be expensive, but it doesn’t have to be, as this four-step road map for developing a CIN proves. Does it have to cost millions to initiate a clinical integration strategy? Contrary to popular belief, we have clients who have generated substantial shared savings and a significant ROI over time, without massive investments. Yes, some financial capital is required for resources the CIN providers can’t bring to the table themselves. But the size of that investment can be miniscule relative to the value it produces: improved outcomes and documentation for payers.
Today’s concerns about physician compensation are the result of the changing healthcare environment. The transition to value is slow, but finally becoming a reality. Proactive hospitals want to ensure that provider incentives are properly aligned with ever-increasing value-based demands. This report focuses on the three big questions HSG receives about adding value to physician compensation; Why are organizations redesigning their provider compensation plans? What elements and parameters must be part of successful compensation plans? How are organizations implementing compensation changes?
Revenue Cycle Management has become an even more complex issue with declining reimbursements, implementation of Electronic Health Records, evolving local carrier determinations (LCD), and payer credentialing [The emphasis on healthcare fraud, abuse and compliance has increased the importance of accuracy of data reporting and claims filing). The efficiency of a medical practice’s billing operations has critical impact on the financial performance. In many cases, patient billings are the primary revenue source that pays staff salaries, provider compensation and overhead operating cost. Inefficiencies or inaccurate billing will contribute to operating losses.
This publication identifies and outlines the necessary characteristics of a fully-functioning clinically integrated network (CIN). What it doesn’t do is detail how hospitals and providers can participate in the value-based care environment during the development process. One common misconception is that the CIN can’t do anything significant until it has obtained the FTC’s “clinically integrated” stamp of approval. While the network must satisfy the FTC’s definition of clinical integration before single signature contracting for FFS rates and contracts can legally start, hospitals and providers can enjoy three key benefits during the development process.
Nearly half of all Medicare beneficiaries treated in the hospital will need post-acute care services after discharge. For these patients, a stay in an inpatient rehabilitation facility, skilled nursing facility or other post-acute care setting comes between hospital and home.
With the proper process, tools, and feedback mechanisms in place, budgeting can be a valuable exercise for organizations while helping hold organizational leaders accountable. Having a proper monthly variance review process is one of the most critical factors in creating a more efficient and accurate budget. Monthly variance reporting puts parameters around what is to be expected during the upcoming budget entry process.
Managing the cost of patient care is the top strategic priority of most hospital CFOs today. As healthcare shifts to more data-driven decision making, having clear visibility into key volume, cost and profitability measures across clinical service lines is becoming increasingly important for both long-range and tactical planning activities. In turn, the cost accounting function in healthcare provider organizations is becoming an increasingly important and strategic function. This whitepaper includes five strategies for efficient and accurate cost accounting and service line analytics and keys to overcoming the associated challenges.
TRENDSETTER
This article takes an in-depth look at how one company is enabling more efficient procure-to-pay processes to streamline healthcare organizations’ financial operations.
This article takes an in-depth look at how one organization is preventing chronic care readmissions through in-home monitoring, patient education, and counseling.
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