A number of health systems have recently noted increasing financial challenges for Medicare Advantage (MA) patient admissions.
One CFO shared, “our rates from MA plans are roughly on par with fee-for-service Medicare. Denials have always been a problem, making our [revenue] capture about 90 percent. But this year it’s dropped to 80 percent…it’s a crisis for us, given fast how MA volumes are growing.”
His team investigated the change and found the cause: mean length of stay for MA patients has jumped sharply. The rise was almost entirely due to difficulties in discharging patients to rehab and skilled nursing facilities.
Key insurers have narrowed their postacute networks, resulting in patients spending days waiting for a bed. “The payers told us they had focused the network on ‘high-performing’ providers. Our data and doctors’ experiences say otherwise. They chose a handful of facilities that are cheap, with questionable quality,” their CMO reported. Attempts to engage payers to solve the problem have gone nowhere:
“They have a disincentive to work with us on this. With case rates, they are saving money if patients are languishing in an expensive hospital bed rather than going to rehab.”
This system is exploring expedited placement and expanding their portfolio of home-based care and postacute offerings, while even considering guaranteeing payment themselves. If you’re having similar challenges or have found solutions to help with transitions of care, we’d love to hear from you and learn more.
Hospital and insurer contract negotiations are often framed as an industry gauntlet, a defined period of time with an objective outcome where big talk does not translate to money. But reimbursement rates secured in new contracts are only one piece of hospitals’ payer-induced headaches.
Traditionally, a health system and commercial insurer would occasionally run into a wall in the contract negotiation process. This could play out into a dispute palpable enough to consumers that it warranted headlines. These impasses generally lasted a matter of weeks with no significant disruptions before outside pressure drove the parties to compromise.
Over the past five years or so, the nature of provider-payer conflicts intensified and may be on the cusp of unprecedented severity given health systems’ financial pressures. At the same time, agreed-upon reimbursement rates are only the tip of the iceberg when it comes to payment health systems can expect from commercial insurers, who have many more defensive plays in their playbook.
They boil down to a classic line from a 1968 movie: deny, deny, deny.
Russ Johnson is CEO of LMH Health, a 102-year-old, independent, nonprofit health system based in Lawrence, Kan. The $350 million organization is anchored by a 174-bed hospital. As he puts it: “We’re not tiny, but we’re not very big.”
Mr. Johnson has spent 37 years working in healthcare, holding senior leadership positions in hospitals and health systems in rural communities and large cities. It’s difficult to identify many things going well when it comes to provider-payer relationships, but Mr. Johnson told Becker’s that it’s the payer movements beneath the reimbursement rates that are worsening and causing greater pain today.
“The part that’s getting worse is the practices behind and underneath the contracts — the sophistication and implementation of pay practices, information systems, artificial intelligence and computer algorithms that are just denying claims by the thousands every month,” he said.
The reimbursement rates secured in contracts are what you can see above water. Beneath, health insurers are moving faster and kicking harder. Throughout the first three months of 2023, about one-third of inpatient and outpatient claims submitted by providers to commercial payers went unpaid for more than 90 days, according to an analysis from Crowe.
“So many more claims are now surfacing with some kind of a fallout on a denial, a downcoding or a pre-authorization — you know, the proverbial dotting the i’s and crossing the t’s, sometimes. But what is abundantly clear is it is not fundamentally about a clinical difference,” Mr. Johnson said.
Denials were once reserved for a sliver of expensive treatments and have now become common occurrence for mundane, ordinary medical care and treatments such as inhalers or familiar medications for chronic conditions a patient has managed for years. The administrative burden is something close to a requirement to prove residency every month to receive electricity or verifying eligibility to work in the U.S. every week for a paycheck — redundant, time-wasting activity for ordinary, essential things.
“For our business office to keep up with what I frankly think is mischief by the payers in terms of denials, pre-authorization, DRG downcoding and a completely unengaged experience trying to negotiate — or to have our physicians call in and do a peer-to-peer conferences about clinical necessity — it’s demoralizing, frankly,” Mr. Johnson said. “Dealing with denial from our payers is one of the biggest dissatisfiers our physicians face.”
Authors of the 2010 Affordable Care Act worried that provisions to expand health insurance access — such as barring health insurers’ refusal to cover patients with preexisting conditions — could cause them to ratchet up other tactics to make up for the change. With this in mind, the law charged HHS with monitoring health plan denial rates, but oversight has been unfulfilled, leaving denials widespread.
Data and numbers on denial rates are not easy to find, but some examination paints a picture rich with variation. An analysis of 2021 plans on Healthcare.gov conducted by KFF found nearly 17 percent of in-network claims were denied, with rates varying from 2 percent to 49 percent. The reasons for the bulk of denials are unclear. About 14 percent were attributed to an excluded service, 8 percent to lack of pre-authorization or referral and 2 percent to questions of medical necessity. A whopping 77 percent were classified as “all other reasons.”
Adding to the inconsistency is the fact that health plan denial rates fluctuate year over year. In 2020, a gold-level health plan offered by Oscar Insurance in Florida denied 66 percent of payment requests; in 2021 it denied 7 percent.
There is much to learn about the ways AI will shape healthcare, and its potential to further expedite and increase denials is concerning. Cigna faces a class-action lawsuit alleging it bypassed requirements for claim review before denial by having an algorithm — dubbed “PXDX” — complete review before having physicians sign off on batches of denied claims. The lawsuit followed a ProPublica report on the practice, which said Cigna physicians denied more than 300,000 claims over two months in 2022 through the system, which equated to 1.2 seconds of review per claim on average.
AI is often touted as a potential, looming replacement to hardworking healthcare professionals, but in the day to day it exacerbates the administrative burdens that already bring them down.
“Nobody becomes a physician because they hope to feel like a cog in a factory,” Michael Ivy, MD, deputy chief medical officer of Yale New Haven (Conn.) Health, told Becker’s. “However, between meeting the demands of payers for referrals, denials of payment and increased documentation requirements in order to assure proper reimbursement and risk adjustment, as well as an increasing number of production metrics, it can be difficult not to feel like a cog.”
A majority of Americans with health insurance said they had encountered obstacles to coverage, including denied medical care, higher bills and a dearth of doctors in their plans, according to a new survey from KFF, a nonprofit health research group. As a result, some people delayed or skipped treatment.
Those who were most likely to need medical care — people who described themselves as in fair or poor health — reported more trouble; three-fourths of those receiving mental health treatment experienced problems.
“The consequences of care delayed and missed altogether because of the sheer complexity of the system are significant, especially for people who are sick,” said Drew Altman, the CEO of KFF, formerly known as the Kaiser Family Foundation.
The survey also underscored the persistent problem of affordability as people struggled to pay their share of health care costs. About 40% of those surveyed said they had delayed or gone without care in the last year because of the expense. People in fair or poor health were more than twice as likely to report problems with paying medical bills than those in better health, and Black adults were more likely than white adults to indicate they had trouble.
Why It Matters: Delayed care can endanger health.
Nearly half of those who encountered a problem with their insurance said they could not satisfactorily resolve it. Some could not obtain the care they had sought, while others said they paid more than expected. Among the nearly 60% who reported difficulty with their insurance coverage, 15% said their health had declined.
“This survey shows it’s not enough to just get a card in your pocket — the insurance has to work or it’s not exactly coverage,” said Karen Pollitz, the co-director for KFF’s patient and consumer protections program.
People have a hard time understanding their coverage and benefits, with 30% or more reporting difficulty figuring out what they will be required to pay for care or what exactly their insurance will cover.
“Insurances are way more complicated than they should be,” said Amanda Parente, a 19-year-old college student in Nashville, Tennessee, who is covered under her mother’s employer plan. She was surprised to find that her out-of-pocket costs spiked recently when she sought treatment for strep throat. While she realized her copayments would be higher, “I guess we didn’t know how drastic it was going to be,” she said.
Background: Insurance coverage is confusing to everyone.
Navigating the intricacies of coverage and benefits were similar regardless of what kind of insurance people had. At least half of those surveyed with private coverage, through an employer, those with an “Obamacare” plan, or a government program like Medicare or Medicaid, said they experienced difficulties.
People might be unhappy with their coverage because they were already concerned about higher inflation and potential layoffs, said Christopher Lis, the managing director of global health care intelligence at J.D. Power, which found that consumer satisfaction with insurers had declined in a recent study. “We’ve got economic conditions that set the stage for concern around coverage and benefits,” he said.
Insurers say people generally report being happy with their plan, and 81% of those surveyed by KFF gave their insurance high ratings. “Health insurance providers are committed to improving access, affordability and convenience for all Americans and will continue to find innovative solutions to work toward this common goal,” said David Allen, a spokesperson for AHIP, a trade group that represents insurers.
What’s Next: How to haggle with insurers or appeal?
Also striking among the survey’s findings was how unaware people were about pursuing appeals of denied coverage and how to go about doing so.
“Most people don’t know who to call,” Pollitz said. Sixty percent of insured adults surveyed did not know they had a legal right to appeal, and about three-fourths said they did not know which government agency to contact for help, particularly respondents with private insurance.
State insurance regulators oversee fully insured policies sold to individuals and small businesses, and the federal Department of Labor has jurisdiction over employer-sponsored insurance.
Many of the problems people have with their insurance could be solved by enforcing existing rules, like federal regulations requiring private insurers to issue understandable explanations of benefits and to maintain accurate, current lists of doctors and hospitals within their networks.
A lack of data about Medicare Advantage plans means there are several unanswered questions about the program, according to an analysis from Kaiser Family Foundation.
The analysis, published April 25, breaks down the kinds of Medicare Advantage data not publicly available. Some missing data is not collected from insurers by CMS, and some data is collected by the agency but not available to the public.
Here are five questions researchers can’t answer without more data, according to Kaiser Family Foundation:
Insurers are not required to report how many enrollees use supplemental benefits and if members incur out-of-pocket costs with their supplemental benefits. Without this data, researchers can’t answer what share of enrollees use their supplemental benefits, how much members spend out of pocket for supplemental benefits, and if these benefits are working to achieve better health outcomes.
CMS does not require Medicare Advantage plans to report prior authorizations by type of service. Without more granular data, researchers can’t determine which services have the highest rates of denial and if prior authorization rates vary across insurers and plans.
Insurers are also not required to report the reasons for prior authorization denials to CMS. This leaves unanswered questions, including what is the most common reason for denials and if rates of denials vary across demographics.
Medicare Advantage plans do not report complete data on denied claims for services already provided. Without this data, researchers cannot determine how often payers deny claims for Medicare-covered services and reasons why these claims are denied.
CMS does not publish the names of employers or unions that receive Medicare funds to provide Medicare Advantage plans to retired employees. Without more data, researchers can’t tell which industries use Medicare Advantage most often and how rebates vary across employers.
Revenue cycle challenges “seem to have intensified over the past year,” according to Kaufman Hall’s “2022 State of Healthcare Performance Improvement” report, released Oct. 18.
The consulting firm said that in 2021, 25 percent of survey respondents said they had not seen any pandemic-related effects on their respective revenue cycles. This year, only 7 percent said they saw no effects.
The findings in Kaufman Hall’s report are based on survey responses from 86 hospital and health system leaders across the U.S.
Here are the top five ways leaders said the pandemic affected the revenue cycle in 2022:
1. Increased rate claim denials — 67 percent
2. Change in payer mix: Lower percentage of commercially insured patients — 51 percent
3. Increase in bad debt/uncompensated care — 41 percent
4. Change in payer mix: Higher percentage of Medicaid patients — 35 percent
5. Change in payer mix: Higher percentage of self-pay or uninsured patients — 31 percent
Stillwater Medical Center in Oklahoma has ended all in-network contracts with Medicare Advantage plans amid financial challenges at the 117-bed hospital, the Stillwater News Press reported Oct. 14.
Humana and BCBS of Oklahoma were notified that their members will no longer receive in-network coverage after Jan. 1, 2023.
“BCBSOK is willing to work with Stillwater Medical Center in finding solutions that will allow Payne County residents continued local access to Medicare Advantage providers,” a BCBS spokesperson told the newspaper.
The hospital said it made the decision after facing rising operating costs and a high prior authorization burden for the MA plans.
“This was a very tough financial decision for the Stillwater Medical leadership team. Our cost to operate has increased 26 percent over the past 2 years,” Tamie Young, vice president of revenue cycle at SMC, told the News Press. “Financial challenges are increased by a 22 percent denial of service rate from Medicare Advantage plans. This is in comparison to a less than 1 percent denial rate from traditional Medicare.”
The American Hospital Association, on behalf of its nearly 5,000 healthcare organizations, is urging the Justice Department to probe routine denials from commercial health insurance companies.
Specifically, the AHA is asking the Justice Department to establish a task force to conduct False Claims Act investigations into the insurers that routinely deny payments to providers, according to a May 19 letter to the department.
The request from the AHA comes after HHS’ Office of Inspector General released a report April 27 that found Medicare Advantage Organizations sometimes delayed or denied enrollees’ access to services although the provider’s prior authorization request met Medicare coverage rules.
“It is time for the Department of Justice to exercise its False Claims Act authority to both punish those MAOs that have denied Medicare beneficiaries and their providers their rightful coverage and to deter future misdeeds,” the AHA said in a letter to the Justice Department. “This problem has grown so large — and has lasted for so long — that only the prospect of civil and criminal penalties can adequately prevent the widespread fraud certain MAOs are perpetrating against sick and elderly patients across the country.”
Keys to achieving revenue integrity and compliance across your organization
It’s old news: Revenue cycle complexity continues to increase, exacerbating existing challenges. And as we tackle those, new ones arise to take their place.
Ever-changing regulations are a given, but adopting value-based reimbursement (VBR) models currently poses a major challenge. New payment models complicating revenue cycle activity become more difficult with additional quality reporting and other requirements. Add in the operational realities of siloed workflows, data proliferation, and disparate systems, and it’s clear why efficient collaboration can seem nearly impossible. Intelligent middle revenue cycle operations that manage to these challenges are vital to achieving revenue integrity and financial stability.
Use the right solutions at the right time
Today’s environment requires sharpening the way you ensure revenue integrity. Providers need an easy, seamless way to manage middle revenue cycle operations, and there are several effective strategies to accomplish that. Of course, it’s important to recognize and make use of your EMR system’s capabilities. It’s also essential to leverage complementary technologies with specific core competencies that will improve revenue cycle performance. For example, a solution that continuously monitors records in real time enables timely auditing, coding adjustments and case completion to reduce billing turnaround and reimbursement delays.
Take a smart approach to enabling technology
Augmenting your core systems with complementary technologies or capabilities on a single, integrated platform makes it much easier to support internal collaboration between different departments or teams. An integrated platform also enables you to seamlessly deploy additional capabilities onto that platform, ensuring speed to value. Instead of using multiple disparate tools, a shared platform enables interdepartmental communication and helps minimize inefficiency. A smart technology platform that crosses departmental siloes and brings transparency across teams is critical. Platforms that leverage clinically aware artificial intelligence and other automation enable staff to proactively focus on the areas where their expertise has the most impact. In addition, when leveraging an integrated platform, one expert team’s work will not get cancelled out by another team’s contributions.
Regardless of which core system you use, integrating technology with targeted competencies and connectivity adds value to the EMR. It can provide a depth of specialized expertise that drives better documentation, coding and real time audit interaction — keys to a high-performing revenue cycle.
Prioritize comprehensive, correct documentation and coding
Unfortunately, it seems the battle against claim denials is here to stay. You can’t overlook the importance of front-end data validation to eliminate rework and inefficiency. However, the ability to ensure complete and accurate clinical documentation for every case will significantly impact revenue capture and reduce the inefficiency of denials and rework.
Broaden the scope of your CDI program with technology that uses clinical intelligence to drive concurrent documentation review for all payers. Getting it right up front contributes to better coding, accurate reimbursement, and appropriate quality measures, all of which are vital to success under VBR.
Increase collaboration with payers
As long as payers and providers continue working at odds, the costly onslaught of denials will persist. In a perfect world, both sides would join forces to find mutually beneficial solutions for claim errors, denials and payment delays. Imagine the savings in administrative inefficiency alone. However, we’re not in that world yet. Therefore, it’s important to make a proactive effort to understand the specifics of each payer’s contract and adjust your internal processes and technology rules accordingly. As operating margins get smaller, organizations have no choice but to increase efficiency and accuracy, and working together with payers can contribute significantly to that goal.
Consolidate, collaborate, communicate
Industry pressures to improve performance are unrelenting, especially around smart solutions, innovation, and increasing both efficiency and the bottom line. Organizations are expected to improve these areas while, at the same time, enabling patient-centric operations. One way to achieve this is to leverage innovative, integrated tools to augment core systems and promote partnership, communication and efficiency across multiple related disciplines.
Consider clinical documentation, coding and auditing. Numerous departments need pieces of that information for different reasons, including utilization review, medical necessity determinations, chart audits and quality monitoring, in addition to bill preparation. A single repository containing up-to-date data in a real-time view driven by supporting workflow, rules and alerts provides consistent and reliable information when and where it’s needed.
As patient care becomes more complex, so does the middle revenue cycle. Seek solutions that will simplify and manage the complexity in an administratively efficient way. Consider your prospective vendor’s core competencies when evaluating solutions and look for integration and intelligent automation that will add the most value to your organization.
Patients saw increases of up to 12% in their out-of-pocket responsibilities for inpatient, outpatient and ED care in 2018.
A new TransUnion Healthcare analysis has found that most patients likely felt a bigger pinch to their wallets as out-of-pocket costs across all settings of care increased in 2018. The new findings were made public yesterday at the 2019Healthcare Financial Management Association Annual Conference in Orlando.
The analysis reveals that patients experienced annual increases of up to 12% in their out-of-pocket responsibilities for inpatient, outpatient and emergency department care last year.
In 2017, the average inpatient cost was $4,068; the average outpatient cost was $990; and the average emergency department cost was $577.
In 2018, the average inpatient cost was $4,659; the average outpatient cost was $1,109; and the average emergency department cost was $617.
FUELING THE TREND
There are certain factors that are influencing this trend, according to Jonathan Wiik, principal of healthcare strategy at TransUnion Healthcare.
“Patients are becoming more aware that emergency care is expensive and somewhat inefficient,” Wiik said. “No one wants to go to the emergency room unless we have to, because we don’t want to deal with the time there or the expense. They aren’t the best place to get primary or even urgent care.”
Another factor, he said, is that providers realize the emergency department is a care setting of last resort for many. Providers want to make sure that have room in the ED for cases that are real emergencies, so they’re essentially curating their patients, steering patients to the most cost effective settings possible — often primary care, which is the least expensive setting.
Noting that the biggest annual increases were in inpatient and outpatient care, Wiik said that was largely a function of utilization and just a general wariness, in addition to the fact that most EDs have pretty flat contracts. Financial communication with patients is also an issue.
“Most people can’t afford the average out-of-pocket, so providers are really trying to educate patients as early as they can about those costs,” said Wiik. “Emergency care is a really hard place to educate people on finances, let alone collect on them.”
RISING COSTS
The analysis found that, during a hospital visit, patients are likely experiencing cost increases that continue the trend of higher out-of-pocket costs. About 59% of patients in 2018 had an average out-of-pocket expense between $501 and $1,000 during a healthcare visit. This was a dramatic increase from 39% in 2017. Conversely, the number of patients that had an average out- of-pocket expense of $500 or below decreased from 49% in 2017 to 36% in 2018.
And with out-of-pocket costs increasing, the trend toward consumerism is growing as more patients, payers and providers transition to lower cost settings of care.
One example: Inpatient care, traditionally the most expensive healthcare option, has seen a leveling off with the percentage of price estimates remaining at 8% between 2017 and 2018. The percentage of outpatient services estimates, generally about one-quarter of the cost of inpatient services, rose in that same timeframe from 65% to 73%.
“Patients are likely seeing more providers and payers recommending that they take advantage of cost-effective healthcare options, which brings down costs for all parties,” said Wiik. “This is especially important as costs continue to rise in all areas of healthcare, particularly in inpatient, outpatient and emergency department services.”
This is having an impact on providers, payers and patients, he said.
“Let’s pretend Joanna had an MRI in her head, and that ran $3,200. That might have been paid by Blue Cross Blue Shield, and $100 out of Joanna’s pocket. Now Joanna’s paying $300. Most patients don’t look up how much the MRI’s going to be. They just get the bill later and try to figure it out. I think the patient portion of the bill is going to be in the 35, 40% range very soon. What that means is we’re quickly approaching half of the bill coming from the patient and half from the payer. That’s not insurance anymore, that’s a bank account.”
A recent Kaiser Family Foundationstudy indicated that 34% of patients are finding it difficult to pay their deductible before insurance kicks in. In addition to patients being challenged to make payments, the trend is that providers are also feeling the pressure of increased denial rates and write-offs, which is increasing bad debt.
Considering these factors together — increased out-of-pocket expenses, a patient’s challenge to make payment, and increased denial rates — collecting payments from all payers is critical for providers. In order for providers to ensure they receive payment for the patient-care services rendered, it is vital that they implement strategies that maximize reimbursements.
HENRY KOTULA 