At a Glance
- Medicaid disenrollment is increasing, which could lead to more uncompensated care and care gaps. Practices should help patients re-establish eligibility or find other insurance options.
- Telehealth brings privacy and security risks. Providers should educate patients on mitigating these risks and have their own strategies to reduce the chances of a breach.
- Value-based payment models may help reduce physician burnout compared to fee-for-service models. Practices should consider developing a value-based care strategy.
Welcome to the October 2023 edition of Vital Signs: a monthly roundup of RCM news for independent practices.
For today’s independent medical practices and medical billing companies, there’s truly never a dull moment. Proactively identifying and addressing potential challenges is key. Focus your attention on these 9 RCM stories and engage in discussions internally about whether and how they might impact your business.
1. New data shows Medicaid disenrollment rates vary by state
The specifics: There is wide variation in disenrollment rates across states, ranging from 66% in Texas to 11% in Illinois, according to continually updated data from KFF. In total, at least 9,531,000 Medicaid enrollees have been disenrolled as of October 26, 2023.
Why it matters: Medicaid disenrollment could increase uncompensated care and promote clinical care gaps.
What’s next: Take proactive steps to notify patients their Medicaid status may have changed, guide them through the process of re-establishing eligibility, or, in some cases, direct them to their state’s health insurance exchange.
2. OCR publishes resources on telehealth privacy and security risk
The specifics: Two new resources from the Office for Civil Rights (OCR) — one for healthcare providers and one for patients — detail privacy and security risks to protected health information when using telehealth services as well as ways to reduce those risks.
Why it matters: Various environmental, technological, and operational factors inherent in telehealth increase privacy and security risks. If you don’t take proactive steps to mitigate risk, you could find yourself facing civil and/or criminal penalties in the event of a breach.
“Form a strategy for how you’ll educate patients about how to ensure privacy and security during telehealth encounters.”
What’s next: Form a strategy for how you’ll educate patients about how to ensure privacy and security during telehealth encounters. For example, you may want to review this tip sheet with patients when they schedule a telehealth appointment. You may also want to post the tips in your waiting area and on your patient portal.
3. Use of patient portals continues to increase
The specifics: The number of people nationwide who were offered and accessed their online medical record or patient portal more than doubled between 2014 and 2022, according to new data published on healthIT.gov. In 2022, the most common reason why patients accessed patient portals was to view test results and clinical notes.
Why it matters: Patients increasingly want the ability to access their health data when and where they need it most. If you don’t offer a patient portal, you may have trouble attracting and retaining patients now and in the future.
What’s next: If you don’t already use a patient portal or you haven’t figured out how to leverage it to promote patient engagement and education, now is the time to strategize. What can you do to educate patients about the portal, how to use it, and what’s included in it? How can you convey the benefits of accessing the portal?
4. AMA provides resources on how to grow and sustain your private practice
The specifics: The American Medical Association (AMA) recently provided several resources to help independent medical practices stay independent and become more profitable. In this article, it organizes those resources into the following categories: business operations, digital health, quality improvement, culture and leadership, and health equity.
Why it matters: The AMA’s latest Physician Practice Benchmark Survey (also released this month) shows that between 2012 and 2022, the share of physicians working in private practices dropped by 13 percentage points from 60.1% to 46.7%, reflecting the difficulties associated with remaining independent.
What’s next: Identify business challenges in your medical practice and take proactive steps to address them. This AMA Private Practice Playbook can help.
5. AAFP study links value-based payments with reduced physician burnout
The specifics: Physicians with the most severe symptoms of burnout had a majority of their revenue from fee-for-service payment models. In contrast, those with little or no burnout had 75% or more revenue from value-based payment arrangements, according to a new study by the American Academy of Family Physicians.
“Physicians with little or no burnout had 75% or more revenue from value-based payment arrangements.”
Why it matters: As physician burnout continues to reach epic proportions, value-based payment models may be one solution. However, as the report points out, these alternative payment arrangements must be well-designed and thoughtfully implemented to empower physicians to be successful.
What’s next: Formalize a value-based care strategy in your medical practice. Ask these questions: What are the model parameters, requirements, and other critical details? What staff will we need to mobilize to manage and provide value-based care? What are the known thresholds for the financial viability of the value-based care program?
6. ICD-10-CM code updates impact preventive service screenings
The specifics: ICD-10-CM code updates effective October 1, 2023, impact screenings for hepatitis B, mammography, and prostate cancer.
Why it matters: Reporting invalid diagnosis codes could cause denials.
What’s next: Review the CMS website for more information about what’s changed.
7. Prepare for Medicare open enrollment
The specifics: Beginning October 15, patients started shopping around to compare coverage options, choose health and drug plans for 2024, and learn about extra help available to those with limited income and resources to pay for Medicare drug coverage. The Medicare open enrollment period ends on December 7.
“The Medicare open enrollment period ends on December 7.”
Why it matters: Independent medical practices and medical billing companies must be ready to answer questions about 2024 Medicare Parts A and B premiums and deductibles and provide patients with resources to help them make important decisions.
What’s next: Strong revenue cycle management (RCM) workflows — particularly those for insurance benefit verification — will be paramount starting January 1 when new Medicare coverage becomes effective. Start thinking about how to make improvements to your processes.
8. Ensure correct Medicare billing for flu vaccines
The specifics: September and October are the best times for people to receive the flu vaccine. However, you need to know what patients are eligible and what codes to report.
Why it matters: Incorrect codes and/or ineligibility could result in claim denials.
What’s next: Review the CMS website for more information about ICD-10-CM, HCPCS, and CPT codes for the flu vaccine, as well as information on Medicare frequency and coverage.
9. Medicare updates compliance guidance for E/M services
The specifics: CMS recently updated its provider compliance tips related to E/M services. The updates address 2023 coding changes, and they also provide up-to-date information about improper payment rate and denial reasons for the 2022 reporting period.
The improper payment rate for all E/M codes is 10.1%, with a projected improper payment amount of $3.1 billion. Insufficient documentation accounted for 32.4% of improper payments for overall E/M codes, while no documentation (5.9%), incorrect coding (52.7%), and ‘other’ errors (9.0%) caused other improper payments. ‘Other’ errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.
“Consider auditing your E/M services regularly.”
Why it matters: E/M services are often a major source of revenue. Denials for these services can affect your bottom line significantly.
What’s next: Focus on provider documentation and accurate code selection. Also, consider auditing your E/M services regularly.
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