Tag Archives: Rev Cycle

Texas Health Resources utilizes work-from-home model to increase revenue cycle productivity

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Whatever hours they’re at their best is when Texas Health Resources wants them to work, system says.

When Texas Health Resources hires new staff members to work in its revenue cycle department, it’s now required — for most functions, anyway — that they work virtually from home. Staff who have been there since before the virtual implementation have the choice, but many choose to go the route of the new hires. It’s a nice perk for the employees, but an even nicer one for the system, which has seen productivity increase significantly since taking this approach.

James Logsdon, THR’s vice president of revenue cycle operations and strategic revenue services, said the concept emerged in 2011 during the Super Bowl.

Dallas was the host city that year, and the big game took place in the midst of a rare ice storm. Logsdon came into work with the wind still whipping and noticed immediately that the office was like a ghost town, with few employees in sight. The system lost three to four days of productivity because people simply couldn’t make it into work, and thus a challenge was born: Turn revenue cycle operations 100 percent virtual within a year.

“It started out as a business continuity plan, but progressed into an initiative,” said Logsdon, recalling the event during the Healthcare Financial Management Association‘s annual ANI conference in Orlando. “It was a drive.”

It took longer than a year, and it may never reach 100 percent; some functions have to stay in-house, particularly with the jobs that involve direct patient interaction. But the effects have been noticeable. Employee satisfaction and morale are at an all-time high, and the turnover rate has been reduced substantially. The system used to lose revenue cycle employees to jobs that paid 10 or 15 cents an hour more, but no longer.

The linchpin of the program’s success is quality. It can’t budge an inch, and employees have to be held accountable.

“The metrics have to be award-winning,” said Logsdon. “You’ve got to set the expectation that this is a privilege. It’s something that could potentially be taken away. Basically, the message was, ‘Don’t let me down.'”

So far they haven’t, and part of the reason is the flexibility the virtual job affords them. Workers are allowed to set their own schedules as long as they put in the minimum eight hours. At whatever hours they’re at their best is when THR wants them to work.

Benefits aren’t just limited to reduced turnover and higher productivity, either. The system allows for better use of its real estate. Where there were cubicles packed tightly together like honeycomb bees, there are now classrooms, war rooms and revenue cycle training areas.

All that saves the system money, since it now uses its existing space for such purposes rather than expanding its footprint. New revenue cycle personnel are expected to work at least 90 days in the office while they undergo their training and education, but after that, they’re released to their virtual offices.

That’s not to say there aren’t challenges. Logsdon said that in some instances employees feel a sense of entitlement, resisting requests to return to the office when the need arises. There are also distractions that differ from the usual office distractions — children, neighbors, friends and family can sometimes intercede. To address this, THR conducts unannounced site visits to make sure everything’s copacetic.

The arrangement has created some new challenges for management, as they now have to ensure employees are using the right equipment and protocols and have an appropriately speedy internet connection. Few issues have arisen.

“Productivity is a topic that always comes up,” said Logsdon. “The requirement for employees, in writing, is to increase productivity by 5 percent. They have no problem hitting it. It’s amazing what you can pull out of people when they’re motivated by the right reasons.”

In Senate Health Care Bill, A Few Hidden Surprises

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http://healthaffairs.org/blog/2017/07/13/in-senate-health-care-bill-a-few-hidden-surprises/

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A low-income person, eligible for Medicaid but not enrolled, is hit by a car or a bullet. Gravely injured, she arrives at the hospital unconscious. Thanks to expert, intensive care that lasts for days or weeks, she gradually recovers. Eventually, her health improves to the point where she can complete the paperwork needed to apply for Medicaid.

Such a hospital can be paid today, thanks to Medicaid’s “retroactive eligibility.” Even if the combination of medical problems and bureaucratic delays prevents an application from being filed and completed for several months, Medicaid will cover the care if the patient was eligible when services were provided.

The newest version of the Senate health bill—the Better Care and Reconciliation Act, or BCRA—would end this longstanding feature of the Medicaid program for beneficiaries who are neither elderly nor people with disabilities. If services are received in one calendar month and the application is completed the following month, the hospital would be denied all payment, even if the patient was eligible and the services were both essential and costly.

It does not matter if the state is led by a governor who understands the devastating impact of this change on hospital infrastructure, especially in rural areas where many hospitals are hanging on by a thread. Today, states have the flexibility to seek waivers that limit retroactive eligibility. Under the BCRA, that flexibility would disappear, as states are forced to end retroactive coverage, whether they like it or not.

Almost certainly, this provision would come as a surprise to most senators who are being asked to support the BCRA. It is only one of many unpleasant surprises lurking largely undiscovered throughout the bill. Following are other selected examples.

A Massive Expansion In Federal Power Over State Budgets

The BCRA grants the federal government startling new power over state Medicaid programs and state budgets. Federal dollars per person would be capped, based on state data about prior spending. But in setting the initial cap for each state, the secretary of Health and Human Services (HHS) could change the amount to rectify what the secretary views as problems in the “quality” of state data. In later years, many states could have their caps adjusted up or down by as much as 2 percent per year. That may sound like a small number, but when applied to billions of federal Medicaid dollars going to a state, it could make or break a state’s entire budget. Medicaid costs triggered by a public health emergency are exempt from the cap, but only if “the Secretary determines that such an exemption would be appropriate.” No statutory limits bound the Secretary’s use of this decision-making authority, which can have an extraordinary fiscal impact on states experiencing an epidemic or other public health crisis.

These provisions would give HHS remarkable new leverage over states, which current or future administrations could use to compel state policy changes in any desired direction. The aggressive use of available leverage has been an unfortunate feature of past administrations’ relationships to state Medicaid programs, but it could become substantially more pronounced with the increased federal authority granted by the Senate bill.

Adding To Uncertainties Surrounding State Expenditures

One recurring theme in Medicaid’s history involves state efforts to claim federal matching funds without spending the requisite state dollars. The Senate bill appears to increase this risk. Under Section 207 in the Senate bill, new opportunities emerge for states desperate to counteract the loss of billions of federal dollars. The bill authorizes unprecedented waivers involving federal funding for tax credits that help consumers buy private health insurance. So long as officials complete a form explaining how the waiver’s replacement of federal safeguards would provide an “alternative means” of increasing “access to comprehensive coverage, reducing average premiums, and increasing enrollment,” a state arguably could convert some or all of this federal money into so-called “pass-through” funds that can be used for purposes unrelated to health care. Unlike the Senate bill’s new public health emergency provisions, which require federal audits of state expenditures, states’ use of pass-through dollars has no statutory audit requirement. A state could convert subsidies meant for health insurance to other uses, or simply use the money to close a budget shortfall. As the Congressional Budget Office (CBO) explained about the virtually identical prior version of this section, the Senate health care bill would “substantially reduce the number of people insured” if states “reduced subsidies, received pass-through funds, and used those funds for purposes other than health insurance coverage.”

Medicaid Treatment For Mental Health And Substance Use Disorders

The bill repeals the current requirement that Medicaid programs must cover all “essential health benefits,” including treatment of mental health and substance use disorders. CBO found that, as the per capita limits in the Senate bill grow progressively tighter, federal Medicaid funding would eventually decline by more than a third, compared to current law. States facing such an enormous drop in federal support may see themselves as having no alternative but to cut services classified as optional, which the Senate bill redefines to include mental health and substance abuse treatment.

A Disordered Process

These problems could have been averted had the legislative process followed regular order, with hearings, legislative staff explaining the bill’s provisions, expert testimony, a public markup, and opportunities to address policy and drafting anomalies. Embedded in a measure with underlying policy goals that the authors of this blog post find fundamentally questionable, the picture that emerges is extraordinarily troubling—a legislative effort to divert more than a trillion dollars away from health care for people who are sicker, poorer, older, and indigent, while leaving states with such massive funding deficits and federal leverage that some states may attempt to stem their losses in ways that harm their vulnerable residents even more.

Even people sympathetic to the bill’s core aims, however, have good reason to oppose the Senate making such consequential decisions without taking the elementary legislative steps needed to detect and avoid terrible mistakes. Continuing to shun all the protections of regular order, the Senate appears poised to act on a bill that almost certainly includes additional unpleasant surprises going beyond those discussed here. With legislation that governs one-sixth of the US economy and that directly affects the health and economic security of millions of constituents, Senators are being asked to vote largely in the dark.

Report: $262B in healthcare claims initially denied last year

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http://www.healthcaredive.com/news/report-262b-in-healthcare-claims-initially-denied-last-year/445758/

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Dive Brief:

  • A new report by Change Healthcare found an estimated 9% of claims submitted to payers last year was initially denied. Of the estimated $3 trillion in charges submitted to payers, $262 billion was initially denied.
  • The report said as much as 3.3% of net patient revenue, an average of $4.9 million per hospital, was “put at risk due to denials.”
  • Change Healthcare said 63% of the claims were recoverable and providers spent $8.6 billion to appeal the claims, which cost an average of $118 per claim.

Dive Insight:

Change Healthcare published “Healthy Hospital Revenue Cycle Index” on Monday at the Healthcare Financial Management Association ANI 2017 conference. The organization said the results “reinforce the tremendous opportunity hospitals have to accelerate cash flow and reduce administrative costs by using advanced analytics to better manage the revenue cycle.”

Change Healthcare bases its index on primary institutional inpatient and outpatient claims processed by the organization in 2016. The company reviewed more than 3.3 billion provider transactions at 724 hospitals that valued $1.8 trillion.

The report found that the Pacific states had the highest denial rate (10.89%) and the most common denial causes were “registration/eligibility” (23.9%) and “missing or invalid claim data” (14.6%).

With many hospitals facing razor-thin margins, these kinds of revenue cycle issues play a role in whether a hospital can grow and reinvest in its facilities. This report shows the importance of a strong revenue cycle that provides relevant information that payers can use to approve claims.

68% of Consumers Did Not Pay Patient Financial Responsibility

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Two in three individuals did not fully pay their patient financial responsibility to hospitals in 2016, a study revealed

 

The number of consumers failing to pay full patient financial responsibility to hospitals increased 15 percentage points from 2015 to 2016, a study showed.

About 68 percent of patients with medical bills of $500 or less did not fully pay their patient financial responsibility to hospitals in 2016, according to a recent TransUnion Health study.

The proportion of individuals failing to pay off full medical bill balances increased from 53 percent in 2015 and 49 percent in 2014.

“There are many reasons why more patients are struggling to make their healthcare payments in full, the most prominent of which are higher deductibles and the increase in patient responsibility from 10% percent to 30 percent over the last few years,” stated Jonathan Wiik, TransUnion Principal for Healthcare Revenue Cycle Management. “This shift in healthcare payments has been taking place for well over a decade, but we are seeing more pronounced changes in how hospital bills are paid during just the last few years.”

• 63 percent of hospital medical bills were $500 or less between 2014 and 2016 and 68 percent of these bills were not paid in full by 2016

• 14 percent of hospital medical bills between 2014 and 2016 were $3,000 or more and hospitals did not receive full patient financial responsibility for 99 percent of the bills in 2016

• 10 percent of hospital medical bills were between $500 and $1,000 from 2014 to 2016 and patients did not pay the full balance on 86 percent of them in 2016

The TransUnion Health analysis confirmed that as patient out-of-pocket costs increase, hospital patient financial responsibility collection rates drop. A recent Crowe Horwath study also revealed that patient collection rates for accounts with balances exceeding $5,000 were four times lower than patient collection rates for accounts with low-deductible health plans.

For patient balances between $1,451 and $5,000, hospitals reported a 25.5 percent collection rate. In contrast, hospitals saw collection rates drop to just 10.2 percent for patient balances between $5,001 and $7,500.

Consequently, patients are more likely to partially pay hospitals for their financial responsibility. The TransUnion Health analysis showed that the proportion of individuals making partial payments toward their hospital medical bills rose from about 89 percent in 2015 to 77 percent in 2016.

Hospitals may see these patient collection trends continue, researchers stated. They projected the percentage of individuals neglecting to fully pay their patient financial responsibility to grow to 95 percent by 2020.

Researchers pointed to the popularity of high-deductible health plans as the primary driver of increased hospital patient collection challenges. In 2015, almost one-quarter of all workers belonged to a high-deductible health plan with a savings options versus just 8 percent in 2009, a 2016 Health Affairs blogpost stated.

The number of employees enrolled in high-deductible health plans is likely to increase, the blogpost continued. More than four of ten employers are considering offering only high-deductible health plans over the next three years.

Provider organizations continue to feel the pressure from increased patient financial responsibility under high-deductible health plans. About 72 percent of providers in a recent InstaMed survey cited patient financial responsibility and collection as their top healthcare revenue cycle management concerns in 2016.

The greatest challenge impacting healthcare revenue cycle management was the growth of patient financial responsibility with 29 percent of respondents, followed by cash flow issues with 21 percent, longer days in accounts receivable with 14 percent, and rise in bad medical debt due to insufficient patient collections with 8 percent.

With unpaid patient financial responsibility reducing hospital revenue, TransUnion Health researchers reported that hospitals wrote off about $35.7 billion as bad medical debt or charity care in 2015. Although overall uncompensated care costs declined in 2015, they added.

“Higher deductibles and the increase in patient responsibility are causing a decrease in patient payments to providers for patient care services rendered,” stated John Yount, TransUnion Vice President for Healthcare Products. “While uncompensated care has declined, it appears to be primarily due to the increased number of individuals with Medicaid and commercial insurance coverage.”

The doctor is out: PCP availability beyond 2020

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The doctor is out: PCP availability beyond 2020

In 2020 and beyond, under the Senate’s BCRA, the working poor will have a very hard time finding primary care providers (PCP) who will schedule appointments with them. Providers, rightly, fear bad debt from high deductible plans. They will discriminate on the ability to pay upfront.

In the NEJM, Karin Rhodes, Genevieve Kenney, and Ari Friedman† looked at PCP appointment availability in the from the end of 2012 to Spring 2013. They found that appointments were usually quickly available if the person had insurance and unavailable if they were cash paying patients who could not afford the median price of services.**

The overall rate of new patient appointments for the uninsured was 78.8% with full cash payment at the time of the appointment (Figure 2). The median cost of a new patient primary care visit was $120, but costs varied across the states, as indicated in the figure legend. Only 15.4% of uninsured callers received an appointment that required payment of $75 or less at the time of the visit, because few offices had low-cost appointments and only one-fifth of practices allowed flexible payment arrangements for uninsured patients.

Why does this matter in the BCRA environment?

The baseline plan will be a plan with a $7,500 deductible for a single person. For people with means, paying $120 for a PCP visit is unpleasant but not onerous. If I had to do that this afternoon, I would grumble as I pull out a credit card. I would pay that credit card off tomorrow after I got the transaction points. Not everyone can do that.

Craig Garthwaite raises a good point this morning:

Primary care providers will seek to minimize their net bad debt.

Michael Chernew and Jonathan Bush looked at how bad debt accumulates as a function of out of pocket expenses at professional offices.

The median PCP cash visit price is a large payment in the Chernew/Bush schema. Most of it will be paid as people with means take out their credit card, their HRA debit card, or their HSA card and swipe it through the machine. But a simple PCP visit will produce significant chasing and write-downs. The study is limited as it only looked at people who were commercially insured. It excludes most low income people who are in the Medicaid gap on an income qualification basis by design. The average income in the study group is highly likely to be higher than the income of people who would move from Medicaid to benchmark plans. Even so, there is significant chasing and write downs. I would predict that applying 100% first dollar obligations on people with even less income than the study population will lead to more provider bad debt. This is because these programs are income qualified and if a person income qualifies for these programs, they probably don’t have a spare $120 floating around or easy access to cheap, revolving credit.

If we assume that some normal PCP visits will include some extra services that increase the contracted payment rate to $200 or more (very large obligations in Chernew/Bush) significant sums will be written down and off. For provider practice viability concerns, providers will very aggressively screen against people with very high deductible insurance who can’t pay the entire amount of the contracted rate price up front at the receptionist desk. This is a very patient unfriendly system.

Most payment reform models focus on delivering more primary care. The objective is to substitute cheap primary care for expensive specialist, inpatient hospital stays and post-acute rehabilitation. This is the concept behind value based insurance design. VBID is supposed to encourage the routine, low cost, regular maintenance of chronic conditions in outpatient or community settings instead of having people end up in the hospital for preventable admissions.

Yet, under the very understandable incentives of primary care physicians wanting to stay in business, access to primary care for the working poor who would have several thousand dollar deductibles that apply to all services, will be greatly restricted because of the cost barrier. If we want all members of our shared society to have decent health and decent lives, should want people to have easy and ready access to primary care. This bill creates strong business incentives to create barriers to primary care access.

Medicare Advantage aggressive coding or fraud

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https://www.balloon-juice.com/category/mayhew-on-insurance/

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The New York Times has a good story from the 15th on a False Claims Act lawsuit filed by a former United Healthcare employee.  It alleges UHC systemically defrauded the US government of billions from up-coding its Medicare Advantage claims to get bigger risk adjustment payments.  This is a big deal.  Medicare knows that the incentive in Medicare Advantage is to make the patients look as sick as possible to maximize upcoding. A recent estimate has coding differentials leading to a $20 billion dollar a year payment differential between Medicare Advantage and Fee for Service Medicare for intrinsically similar patients.

At the heart of the dispute: The government pays insurers extra to enroll people with more serious medical problems, to discourage them from cherry-picking healthy people for their Medicare Advantage plans. The higher payments are determined by a complicated risk scoring system, which has nothing to do with the treatments people get from their doctors; rather, it is all about diagnoses.

Diabetes, for example, can raise risk scores by varying amounts, depending on a patient’s complications. So UnitedHealth gave people with diabetes intensive scrutiny, to see if they had any other conditions that the diabetes might have caused.

As Mr. Poehling’s lawyer, Mary Inman, described it, the government would pay UnitedHealth $9,580 a year for enrolling a 76-year-old woman with diabetes and kidney failure, for instance, but if the company claimed that her diabetes had actually caused her kidney failure, the payment rose to $12,902 — an additional $3,322. Ms. Inman is with the law firm of Constantine Cannon in San Francisco.

We need to differentiate between aggressive coding and fraud.  The key question in this example is not whether or not UHC got a doctor to say that the kidney failure was caused by diabetes but whether or not the evidence in the chart supports that assertion.

If it is medically supported from the chart, history and corroborating results, this is not fraud.  It is aggressive coding designed to maximize revenue.  If it is not supportable, then it is either fraud or abuse.  That will be the key area of argument.  Does the evidence show that the diagnosis codes that UHC is chasing are supportable by medical evidence?

Betsy Nicoletti is a coding specialist who shared her coding book with me.  I want to highlight a legitimate example of what happens at every health plan that has risk adjusted plans.  The example is about diabetes:

Florida Blocked From Enforcing Medicaid Reimbursement Law

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https://www.bna.com/florida-blocked-enforcing-n57982087249/?utm_campaign=LEGAL_NWSLTR_Health%20Care%20Update_042817&utm_medium=email&utm_source=Eloqua&elqTrackId=bf6286463e8f467e8a6540bd7cc98965&elq=06333bede9b64b329320b375191f3295&elqaid=8325&elqat=1&elqCampaignId=6347

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Florida can’t enforce a state law that allowed the state’s Medicaid agency to seek reimbursement from patients who received third-party settlements ( Gallardo v. Dudek , 2017 BL 128992, N.D. Fla., No. 4:16-cv-116, 4/18/17 ).

Judge Mark E. Walker of the U.S. District Court for the Northern District of Florida ruled that Florida’s Medicaid reimbursement statute was preempted by the federal Medicaid Act. The court barred the state from using the statute to satisfy any payment lien against a Medicaid patient whose settlement includes payment for both past and future medical bills.

The court’s decision represents a tension that many states face when dealing with Medicaid reimbursement. The Medicaid Act requires the state to attempt to recover money paid for medical expenses to patients whose injuries are caused by third parties. However, the states are prevented from seeking to obtain the entire amount of a third party settlement and are limited to the amounts set aside for medical expenses.

The court cited a U.S. Supreme Court decision from 2006, Ark. Dept. of Health & Human Servs. v. Ahlborn , 547 U.S. 268 (U.S. 2006), which interpreted the anti-lien provisions of the Medicaid Act as limiting a state to a proportional reimbursement, representing that portion of any settlement or judgment that represents past medical bills. However the provision that the supreme court interpreted in that case and that the court relied on in this case could be changing as of Oct. 1.

At least one practitioner told Bloomberg BNA that the change, which has been delayed repeatedly, could result in this Florida statute suddenly becoming legal.

One Size Doesn’t Fit All

At issue in this case was Florida’s recovery law, which established a formula for determining how much of a third party settlement can be sought by the state Agency for Health Care Administration. Under that law, the AHCA can seek either 37.5 percent of the settlement, or the actual amount paid for medical expenses, whichever is less.

The case was brought by the family of Gianinna Gallardo, a 13-year-old girl who was hit by a car and ended up in a persistent vegetative state as a result of her injuries. The AHCA paid about $800,000 for her medical treatments. Gallardo’s parents sued the individual responsible for her injuries in a suit that they valued at $20 million. They settled for 4 percent of the estimated value of the suit, or $800,000

Following its formula, the AHCA instituted a lien on the settlement of $300,000, which represented 37.5 percent of the total amount. The Gallardos challenged the lien, claiming it didn’t reflect a proportional reimbursement and it accessed funds in the settlement, which had been set aside for Gianinna’s future medical bills.

The court agreed with the Gallardos. According to the court, the law’s “one-size-fits-all” formula didn’t match with the supreme court’s decision in Ahlborn and was thus improper. The court said the Medicaid Act only permitted the AHCA to recoup a portion of a settlement that had been designated to cover past medical bills.

Floyd Faglie of Staunton & Faglie in Monticello, Fla., who represented the Gallardo family in the litigation, said his clients were very pleased with the court’s ruling.

“This is a tremendous benefit to the Gallardo family, to Gianinna Gallardo in particular,” he told Bloomberg BNA. “What the court has done is leveled the playing field for people to challenge Medicaid liens asserted against tort settlements and made it fair.”

A representative for the AHCA declined to comment on the ongoing litigation.

 

Hospitals increasingly employing pre-payment strategies to avoid bad debt

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http://www.beckershospitalreview.com/finance/hospitals-increasingly-employing-pre-payment-strategies-to-avoid-bad-debt.html

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The increase in prevalence of high-deductible health plans under the ACA has led to more unpaid hospital bills among the insured population. To combat mounting bad debt, many hospitals have begun experimenting with pre-payment strategies, many of which require patient payment before scheduled care, according to Reuters.

In 2015 U.S. hospitals faced nearly $36 billion in uncompensated care, with much of that coming from unpaid patient bills.

Hospitals are addressing this in a variety of ways. Henry County Health Center in Mt. Pleasant, Iowa, sends patients cost estimates along with pre-surgery medical advice and information.

“Most patients are appreciative that we’re telling them up front,” said David Muhs, CFO of HCHC, according to the report. The hospital even provides a discount to patients for early payment. While the cost estimates help prevent surprisingly high medical bills after medical procedures, they also lead some patients to skip or delay care. Others elect to use no interest loans available through the hospital, Mr. Muhs told Reuters.

After Winston-Salem, N.C.-based Novant Health began offering no-interest loans its patient default rate dropped from 32 percent to 12 percent, according to the report.

The trend of pre-payment strategies is expected to continue this year amid increasing bad debt, according to the report. According to government data cited by Reuters, the average deductible in 2017 for the least expensive of ACA marketplace plans is $6,000 for an individual, up 18 percent from 2014. A Kaiser Family Foundation poll found that 45 percent of Americans would have difficulty paying an unplanned $500 medical bill.

 

14 things to know about medical coding

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http://www.beckershospitalreview.com/finance/14-things-to-know-about-medical-coding.html

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Medical coders play a crucial role in the revenue cycle process, as they help ensure health systems, hospitals and physicians are properly reimbursed for the services they provide.

Here are 14 things to know about medical coding.