Patient Access, Registration Errors Lead to Most Claim Denials
By Jacqueline LaPointe | October 25, 2023
Hospitals and health systems are facing more claim denials as front-end revenue cycle processes lead to errors.
A recent survey conducted by the Healthcare Financial Management Association’s Pulse Survey program for AKASA polled more than 350 CFOs and revenue cycle leaders at hospitals and health systems. Nearly half of the financial leaders (47 percent) said claim denial rates increased compared to last year, with 37 percent reporting an increase of at least 5 percent.
While most hospitals and health systems saw a significant increase in claim denial rates, only 2 percent of respondents said their claim denial rates decreased by 5 percent or more. Meanwhile, 27 percent said there was no change in claim denial rates versus last year and 24 percent reported a decrease under 5 percent.
As claim denial rates ticked up, healthcare CFOs and revenue cycle leaders agreed that errors on the front end of the revenue cycle caused the most claim denials.
When asked to rank the most common reasons for initial claim denials, the top reason was errors in patient access and registration. This means eligibility errors and missing prior authorizations were the most common reasons for hospital claim denials this year.
Healthcare CFOs and revenue cycle leaders also ranked a lack of documentation to support medical necessity and missing or incorrect patient information as the most common reasons for initial claim denials behind errors in patient access and registration.
Other reasons for initial claim denials included physician documentation issues, utilization management, coding errors, duplicate claims, and untimely filing.
Claim denials are an expensive problem for healthcare providers. Another recent survey conducted by Plutus Health found that claim denials are the greatest revenue cycle management challenge for healthcare organizations as the process faces regular backlogs. More than one in five respondents (22 percent) said organizations — which generate annual revenues between $25 million and $5 billion — lose over half a million dollars in annual revenue each year because of denied claims.
Healthcare organizations are making claims denial management a top priority as they cannot afford to lose more money. Trends in initial claim denials indicate a need to improve front-end revenue cycle processes to prevent denials from happening in the first place.
“This new data confirms what we all know: Issues at the front end trickle down into the entire reimbursement process. When your patient access operations run smoothly, you’re setting your downstream workflows and teams up for success,” Amy Raymond, SVP of revenue cycle operations and deployments at AKASA, said in the survey.
To read more, go to Revcycle Intelligence.
Congress Must Protect Physicians from Medicare Cuts: MGMA
By Richard Payerchin | October 24, 2023
Medicare cuts are coming and that’s bad news for physicians, but there is still time for federal lawmakers to act.
The Medical Group Management Association (MGMA) submitted its policy analysis on Medicare in comments for the House Committee on Energy & Commerce. The committee’s Subcommittee on Health has been meeting this month to discuss pending legislation, pressing issues in health care, and how federal regulations are affecting physicians, patients, and the health care sector.
Debate and testimony started in the hearing “What’s the Prognosis? Examining Medicare Proposals to Improve Patient Access to Care & Minimize Red Tape for Doctors.” MGMA Senior Vice President-Government Affairs Anders Gilberg submitted written comments for that hearing.
“While MGMA is supportive of a fiscally responsible Medicare system that puts patients first, we remain concerned that current policies place unnecessary administrative burdens on medical groups, thus impacting access to care,” said the letter from Gilberg to subcommittee Chair Rep. Brett Guthrie (R-Kentucky) and Ranking Member Rep. Anna Eshoo (D-California).
Next year could bring a 3.36% cut in the conversion factor, as proposed by the U.S. Centers for Medicare & Medicaid Services. Congress needs to work stop that, Gilberg said. From 2001 to this year, Medicare physician payment has effectively decreased by 26% when adjusted for inflation, he said.
An alternative is in the bill known as the “Strengthening Medicare for Patients and Providers Act.” It would create a yearly Medicare physician payment update tied to inflation, based on the Medicare Economic Index, Gilberg said.
“Addressing the proposed conversion factor cut and providing sustainable reimbursement will allow medical groups to thrive and focus on providing high-quality care,” he said in the letter.
You can take action on H.R. 2472 – Strengthening Medicare for Patients and Providers Act here.
To read more, go to Medical Economics.
8 Providers Being Acquired by Payers
By Rylee Wilson | October 23, 2023
Here are eight providers that payers have acquired or announced plans to acquire in 2023:
1. BCBS North Carolina plans to purchase all 55 North Carolina locations of FastMed, a national chain of urgent care clinics.
2. Humana‘s CenterWell Primary Care will purchase the bulk of Cano Health’s centers in Texas and Nevada for $66.7 million.
3. UnitedHealth Group’s Optum plans to merge with home health and hospice provider Amedisys. The $3.3 billion deal was green-lighted by shareholders but faces scrutiny from the Justice Department.
4. CareSource plans to acquire a new affiliate, Radiant Alliance, a nonprofit organization composed of Metta Healthcare, the parent company of Ohio’s Hospice and Pure Healthcare, and United Church Homes, pending regulatory approval. Metta Healthcare employs more than 1,400 people in 59 countries throughout Ohio and provides long term care for those with chronic illness or in need of end-of-life care.
5. CVS Health completed its $10.6 billion acquisition of primary care company Oak Street Health.
6. UnitedHealth Group’s recently acquired LHC Group plans to buy Delaware-based home health company Summit Home Care.
7. Optum purchased Middletown, N.Y.-based Crystal Run Healthcare, a multispecialty physician group with over 400 providers across more than 30 locations.
8. UnitedHealth Group closed on its $5.4 billion acquisition of home health firm LHC Group in February. Lafayette, La.-based LHC employs about 30,000 people, including front-line care providers and administrative and support personnel. Many of LHC’s home-health and hospice operations are owned in partnership with hospital systems across 37 states and more than 960 locations.
To read more, go to Becker’s Payer Issues.
Colorado to Remove CRNA Supervision Requirement
By Claire Wallace | October 20, 2023
Colorado Gov. Jared Polis has sent a letter to CMS requesting the removal of supervision requirements for certified registered nurse anesthetists in the state.
Colorado joins more than 20 states that have opted to remove supervision requirements, according to an Oct. 19 press release from the governor’s office.
The change has already been in place in rural Colorado for more than a decade, according to the release.
“By allowing CRNAs to focus on patients rather than supervisors, the state can help hospitals be more efficient and ensure the skills of nurses are available to more patients who need care and assistance,” the release reads.
In 2010, former Colorado Gov. Bill Ritter opted out of Medicare’s CRNA supervision requirements at rural and certain critical access hospitals.
Colorado state lawmakers, the Colorado Nurses Association, Healthier Colorado, Rural Hospital Center, UC Health and the Colorado Hospital Association have expressed support for Mr. Polis’ decision.
Several other states have submitted similar CMS requests, including Delaware in June.
To read more, got to Becker’s ASC.
Employer Health Insurance Premiums Surge: 5 New Findings
By Erica Carbajal | October 18, 2023
Nearly 153 million Americans rely on employer-sponsored health coverage, and costs are on the rise for both workers and employers.
KFF published findings from its 25th annual Employer Health Benefits Survey on Oct. 18, which showed family premiums for employer-sponsored health coverage reached an average of nearly $24,000 this year, up 7% from 2022 and the highest rate increase in a decade.
Average annual premiums for individual coverage also increased by 7% to $8,435.
“We’ve had this period of super-high inflation and now premiums are catching up,” Matthew Rae, co-author on the report and associate director of KFF’s healthcare marketplace program, told USA Today.
The findings are based on KFF’s survey of more than 2,100 public and private firms from January to July.
Four more findings:
– This year, workers on average contributed $6,575 toward the cost of family coverage, up nearly $500 from last year. Employers covered the rest.
– Nearly a quarter of employers surveyed indicated they will increase workers’ premium contributions in the next two years.
– Relative to the 7% increase in average premiums, employee wages grew about 5.2%, and inflation grew 5.8%.
– In 2023, the average deductible amount is $1,375, about the same as last year. Researchers called the 7% increase in annual premiums a “big change compared to last year, when there was not a statistically significant increase from the year prior and suggests that the higher overall prices we have seen since 2022 in the rest of the economy have begun to affect premiums.”
Access the full KFF survey findings here.
To read more, go to Becker’s Payer Issues.
What’s New for Medicare Open Enrollment in 2023: 5 Notes
By Rylee Wilson | October 13, 2023
Medicare open enrollment begins Oct. 15 and runs through Dec. 7. During this time, enrollees can make changes to their Medicare coverage for the upcoming year, such as switching between Medicare Advantage plans, switching from MA to traditional Medicare and choosing new supplemental coverage.
Here are five updates to note ahead of the open enrollment period:
1. Premiums and deductibles for Medicare part B will increase slightly in 2024. Part B monthly premiums will increase by around 6 percent to $174.70, and annual deductibles will increase around 6 percent to $240. The average monthly premium for Medicare Advantage plans is projected to increase by less than $1 in 2024, according to CMS.
2. Insurers are expanding their Medicare Advantage offerings for 2024, entering new markets and states. In addition to adding new markets, some insurers are introducing new partnerships and plan options. Alignment Health will launch a co-branded plan with grocery delivery platform Instacart, and SCAN Health plan will introduce the first Medicare Advantage plan designed for women.
3. CMS will put new rules in place governing prior authorizations in Medicare Advantage plans in 2024. Per a final rule CMS issued in April, prior authorization policies may be used only to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary. Plans also cannot impose any prior authorizations for an active course of treatment during the first 90 days a member is enrolled in a plan.
4. Some hospitals and health systems are dropping Medicare Advantage plans. At least one health system, Bend, Ore.-based St. Charles Health System, advised its patients to choose traditional Medicare over Medicare Advantage during the open enrollment period.
5. Marketing for Medicare Advantage plans could look different during this open enrollment period. CMS is requiring all Medicare Advantage television advertisements to be submitted to the agency for approval before airing. The agency is also barring any Medicare Advantage advertisements that do not mention a specific plan to cut down on misleading claims.
To read more, go to Becker’s Payer Issues.
ASA Issues Joint Statement on New NSA Guidance
October 10, 2023
On Friday October 6th, the Centers for Medicare & Medicaid Services (CMS) announced new guidance in response to the August ruling in Texas Medical Association v. United States Department of Health and Human Services (“TMA III”) that vacated several provisions of the existing No Surprises Act (NSA) regulations.
The American College of Emergency Physicians, American College of Radiology, American Society of Anesthesiologists, Emergency Department Practice Management Association, and Radiology Business Management Association are strongly opposed to this newest guidance, which further broadens the already significant discretion health plans had on how they may calculate qualifying payment amounts (QPAs) under the NSA’s original implementation.
In the announcement, the Departments state that no additional guidance is expected to be provided to health plans about how to calculate the QPA, and instead, simply leaves insurers the discretion to calculate QPAs using their own “good faith” interpretation of the TMA III ruling and remaining regulations.
As well, the Departments stated they will provide only very limited enforcement for health plans on QPA calculation issues until at least May 1, 2024, if not to November 1, 2024. Our organizations are very concerned about this delay in full enforcement.
There is already lax enforcement of insurer compliance with the NSA’s requirements, including the fact that many plans are seemingly being allowed to delay payment to physicians (or simply not pay at all) following an independent dispute resolution ruling, without any consequences imposed by the Departments.
This newest announcement providing insurers with significant enforcement relief on the QPA further erodes the critical foundations Congress built into the NSA when it passed these important consumer protections into law and seems contrary to the federal court order which stated that this could be done expeditiously.
Further, we are concerned that the Departments are providing no instructions to certified IDR entities on how to evaluate QPAs that are calculated based on the methodology that was invalidated by the district court decision.
Together, these troubling policies will lead to additional burdens on the IDR process as providers continue to seek remedy for unreasonably low payments from insurers, and certified IDR entities struggle to make determinations in light of the TMA III decision without any additional information.
We ask that the Departments immediately re-consider this decision and promptly issue specific guidance on health plan obligations to calculate QPAs in line with the federal district court ruling and issue additional instructions to certified IDR entities on how to evaluate QPAs that are based on an invalidated methodology.
Our organizations are also concerned about the details of the partial re-opening of the federal independent dispute resolution (IDR) portal. Prior to this, the portal was closed to otherwise eligible disputes that had not been initiated by August 3,2023.
While we are pleased that single determinations for eligible disputes are now permitted, we are discouraged that batched determinations continue to be in a holding pattern following the earlier TMA IV ruling.
Without any improved guidance on batching, the administrative efficiencies that come from being able to batch disputes will not be realized, thereby increasing costs for physician practices, while causing the current backlog of unresolved disputes to continue to grow.
We urge the Departments to quickly re-open the portal to batched determinations, and concurrently provide effective guidance to all affected parties.
To read more, go to ASA’s website.
ASA Urges Congress to Block New Payment Code and Cuts
October 6, 2023
On October 4, ASA joined 46 other organizations in urging Congress to block the implementation of G2211, a new Medicare payment code. Absent Congressional intervention, the new code will take effect on January 1, 2024, and result in payment cuts to a full range of Medicare procedures, including anesthesia, pain and critical care procedures.
The implementation of G2211, which was previously delayed, was announced as part of the Medicare Physician Fee Schedule proposed rule, the draft regulation setting Medicare payment rates for 2024.
CMS explained that the code, a special primary care service payment boost, is intended to reflect complexity related to evaluation and management (E/M) services for patients with serious or complex conditions. The add-on may only be used in conjunction with office and outpatient E/M billing codes. CMS intends to implement the code in a budget neutral manner, which means payments for other services will be cut to finance the payment boost for the E/M services.
CMS has calculated that as much as 90% of the over 3% CMS proposed 2024 cuts to both the anesthesia and resource-based related value scale (RBRVS) conversion factors are the result of the budget neutral implementation of the add-on code.
To read more, go to ASA’s website.
3 States Dropping Payers from Medicaid Contracts
By Rylee Wilson | October 4, 2023
Some states are opting for new providers to administer their Medicaid managed care programs.
Here are three states dropping contracts Becker’s has reported since July:
1. Indiana said it will no longer award Molina Healthcare a contract to manage a new Medicaid long-term services and supports program, according to regulatory filings from Molina. The company said it was unable to secure approval from CMS to have a dual eligible special needs program in place in Indiana by 2024. The state is proceeding with plans to award contracts to manage the program to Humana, UnitedHealthcare and Anthem Blue Cross Blue Shield.
2. New Mexico will not renegotiate a Medicaid contract with Centene subsidiary Western Sky Community Care. In August, the state said it plans to award contracts to Blue Cross Blue Shield of New Mexico, Presbyterian Health Plan, United Health Plan and Molina Health Plan.
3. Idaho dropped Optum as the managed care contractor for its behavioral health plan, awarding a four-year, $1.2 billion contract to Centene’s Magellan Healthcare subsidiary. Optum held the contract for a decade.
To read more, go to Becker’s Payer Issues.