Some State Surprise Billing Resolution Processes Favor Providers
By Jacqueline LaPointe | October 25, 2022
The No Surprises Act gives states the opportunity to enforce surprise billing provisions, but most are leveraging the federal independent dispute resolution process to determine out-of-network rates, according to a new report.
The report from Commonwealth Fund analyzes state and federal regulatory documents to evaluate the federal-state partnerships implementing the No Surprises Act. The analysis finds that most states are partnering with the federal government, and this includes payment disputes.
The No Surprises Act looks to fill gaps in existing state laws protecting consumers from surprise medical bills, including in areas where other federal laws preempt state actions. For example, the Employee Retirement Income Security Act of 1974 (ERISA) bans states from adopting surprise-billing protections for consumers enrolled in self-funded plans. The Airline Deregulation Act also prohibits states from applying protections for consumers using air ambulance services. The No Surprises Act provides consumer protections for both.
The federal law has a framework similar to the Affordable Care Act, the report says. States can directly enforce consumer protections, the federal government can directly enforce them, or the state and federal governments can collaborate.
Just Idaho, Iowa, Maryland, Pennsylvania, and West Virginia have opted for full state enforcement, the report shows. Meanwhile, Wyoming, Oklahoma, Missouri, Louisiana, Indiana, and Alabama have elected for full federal enforcement.
The majority of states—three-fourths, according to the report—are sharing enforcement responsibilities with the federal government.
States are also more willing to enforce provisions relating to payers. Sixteen states will take on the responsibilities themselves, while 26 will share with the federal government. Meanwhile, just five states plan to enforce provisions related to providers and facilities, and 27 share responsibilities with the federal government. That leaves 18 states leaving enforcement of provider and facility provisions solely to the federal government and just 8 states leaving enforcement of payers.
Each enforcement approach is different, but the report shows that, when it comes to out-of-network payment disputes, the majority of states will use the federal independent dispute resolution process.
To read more, go to Revcycle Intelligence.
House Progressive Bill Wants to Take Medicare Out of Medicare Advantage’s Name
By Robert King | October 13, 2022
New legislation from two House progressive lawmakers wants to change the name of Medicare Advantage (MA) to “alternative private health plan,” the latest criticism of the program ahead of open enrollment.
The Save Medicare Act (PDF), introduced Thursday by Reps. Mark Pocan, D-Wisconsin, and Ro Khanna, D-California, argues that MA plans mislead seniors. The introduction of the bill—right ahead of open enrollment that starts Saturday—shows that while MA traditionally has wide bipartisan support, there remains opposition among more progressive lawmakers.
“Medicare Advantage is just private insurance that profits by denying coverage and the name is being used to trick seniors into enrolling. That’s not right,” said Khanna in a statement. “This bill will prevent these private insurers from labeling themselves as Medicare and allow us to focus on strengthening and expanding real Medicare instead.”
The legislation would relabel MA as alternative private health plans and significantly fine any insurer that uses Medicare in plan titles or advertisements.
Pocan said in a statement that Congress should instead work on expanding traditional Medicare to include dental, vision and hearing benefits that are offered by MA plans.
“These non-Medicare plans run by private insurers undermine traditional Medicare,” he said. “They often leave patients without the benefits they need while overcharging the federal government for corporate profit.”
The bill doesn’t appear likely to make it through the House, where more than 80% of lawmakers recently wrote a letter signaling their support for the growing program. However, it underscores criticism that progressives have of MA, especially private insurers’ role in it and reports of overspending.
To read more, go to Fierce Healthcare.
Survey Explores Factors in Job Satisfaction, Stress Among US-Based Intensivists
October 14, 2022
A new national survey has shone a much-needed light on the state of stress, satisfaction and turnover among U.S.-based intensivists.
The survey found that while these critical care physicians report high levels of overall job satisfaction, it comes at the cost of low levels of work–life balance satisfaction and a high frequency of job stress. The survey also yielded interesting insights into factors that may affect satisfaction, stress and reasons for turnover.
“When I first moved to critical care from anesthesiology, it was a completely different environment [from] the OR,” said Cortessa Russell, MD, an assistant professor of anesthesiology and critical care at Columbia University Medical Center and NewYork Presbyterian Hospital, both in New York City. “It was much more stressful,” she said.
“My collaborator on this project, Claire Barshied, PhD, is a medical sociologist,” Russell continued. “Together, we started wondering what makes critical care so challenging and what factors might come into play in terms of people’s job satisfaction.”
To help answer these questions, the researchers designed a cross-sectional electronic survey that was sent to U.S.-based physician members of the Society for Critical Care Medicine in June 2016. The survey posed 25 questions regarding four dependent variables:
satisfaction with work,satisfaction with work–life balance,frequency of stress at work, andturnover intention.
To read more, go to Anesthesiology News.
Practices Most Frustrated With Prior Authorization, Then No Surprises Act
By Jacqueline LaPointe | October 12, 2022
Prior authorizations are still the top regulatory burden according to executives from group practices, while No Surprises Act compliance has debuted on the list this year as the second most burdensome regulatory.
Those are the findings from MGMA’s 2022 Annual Regulatory Burden Report, a survey of executives from over 500 group practices. Of the practices responding this year, more than three-quarters are independent and about 64 percent have less than 20 physicians.
Fifteen percent are practices with over 100 physicians.
Yet again, group practice leaders say they are facing more regulatory burden compared to last year. In the 2022 report, 89 percent of respondents said regulatory burden on their practice has increased over the last 12 months. That is down just slightly from 91 percent in the 2021 report.
Meanwhile, less than one percent of respondents said regulatory burden has decreased and 11 percent said it has not changed.
Compliance with health policies and regulations is a major challenge for medical practices and one that can detract from patient care, MGMA says. An overwhelming majority of group practice executives (97 percent) agreed that a reduction in regulatory burden would allow their practices to reallocate resources toward patient care.
Some executives added that staffing shortages are making compliance even more burdensome while increasing costs coupled with decreasing reimbursement rates mean there are no resources available to put toward regulatory issues.
“In a time of runaway inflation and unprecedented workforce shortages, the federal government is layering on additional regulatory burdens that, while in theory are beneficial to patients, act more as an impediment to delivering care,” Anders Gilberg, SVP of Government Affairs at MGMA, said in a press release.
To read more, go to Revcycle Intelligence.
Medical Coding is the Next Stop for Artificial Intelligence in Healthcare
By Jacqueline LaPoint | October 3, 2022
To a layperson, medical codes look like a different language, and in a way they are. Medical coding is a highly complex process in healthcare in which clinicians and revenue cycle staff work together to translate clinical encounters into billable codes for not only reimbursement but other performance tracking efforts. The codes that ultimately end on claims tell the story of a patient’s encounter.
Understanding a clinical encounter is extremely important for patient care and for keeping the doors open. However, in a world of ever-changing payer rules and documentation requirements, medical coding is perhaps more complex than ever.
“Something that is challenging for us is getting payment in a timely fashion so that we can actually make payroll to make sure doctors and APPs [advanced practice practitioners] are paid correctly,” explains Eric Wilke, MD, Eric Wilke, an emergency medicine doctor and chief operations officer at TECHealth, an ER physician staffing company.
Medical coding can get in the way of timely reimbursement. Payers may reject or deny claims because of medical coding errors or missteps. In fact, a survey of hospital executives found that about a third cite coding as their top concern when it comes to denials and denials prevention.
With denial rates on the rise, optimizing medical coding to prevent claims denials is critical. Healthcare organizations must identify the right codes for services provided during a clinical encounter while adhering to payer requirements. Organizations must ensure they are not leaving money on the table by neglecting to code a service or applying the appropriate severity level or modifier.
Organizations are also trying to implement medical coding best practices with fewer coders and revenue cycle staff.
“We’ve experienced hiring challenges for billing and coding positions, especially in the wake of COVID-19,” Wilke says. “We had extended interviews to several people, and they never even bothered to show up.”
The “Great Resignation”—a term used to describe high levels of turnover during and in the aftermath of the COVID-19 pandemic—has hit healthcare particularly hard. Provider organizations have especially faced shortages of qualified revenue cycle talent, with entry-level roles taking an average of 84 days and over $2,000 to fill. Mid-level revenue cycle positions, which require six to ten years of experience, are taking an average of 153 days and over $3,500, survey results also show.
Many healthcare organizations choose to offshore medical coding to combat domestic staffing shortages and the high costs of filling open roles. But for organizations like TECHealth, “all of the work we were doing was domestic,” Wilke states.
Unfortunately, Google Translate does not recognize medical codes as a language. However, TECHealth found a “bit of an equalizer in that standpoint.”
To read more, toRevcycle Intelligence.
ASA Joins Coalition in Support of Legislation to Avert Medicare Payment Cuts
October 3, 2022
Last week, ASA joined with over 100 medical organizations representing more than one million physician and non‐physician health care clinicians in support of H.R. 8800, the Supporting Medicare Providers Act and urging immediate action to avert the upcoming Medicare payment cuts, which are scheduled to take effect January 1, 2023. The letter commends Congressman Ami Bera, MD (D-CA-07) and Congressman Larry Bucshon, MD (R-IN-08) for introducing the legislation and also calls on lawmakers to continue discussions on long-term reforms that will allow Medicare payments to account for inflation and fairly pay health care providers.
Please contact your lawmakers and urge them to co-sponsor H.R. 8800 to support the financial stability of medical practices across the country and safeguard patient access to high-quality care.
To read more, go to ASA’s website.