At a Glance
- CMS has added utilization data for 6 new procedures to the Medicare.gov website’s Care Compare tool
- New lab codes will be effective October 1, with others being deleted — affecting accurate billing and revenue integrity
- The AMA and other healthcare organizations are urging congressional leaders to focus on policy reforms to sustain medical practices
- Coders and billers can enter or change medical codes in a patient’s health record in collaboration with physicians to ensure compliance
- Medicare Advantage plans denied 7.4% of prior authorization requests in 2022, with most appeals resulting in overturned denials
- A physician in Tulsa, Oklahoma, paid over $600K to resolve a False Claims Act case involving fraudulent billing while out of the office
- Patients are increasingly interacting with AI for health information, but many doubt the accuracy of AI-provided medical advice
- An upcoming ICD-10-CM Coordination and Maintenance Committee Meeting will discuss 40 ICD-10-CM topics
- A recent study links adverse childhood experiences (ACEs) to higher healthcare utilization and spending, with significant societal costs
- CMS received over 16,000 complaints related to the No Surprises Act by June 2024, leading to over $4 million in monetary relief
Welcome to “Vital Signs,” your go-to monthly digest of all things related to RCM tailored specifically for independent practices. You can access previous editions for the top insights and developments here.
It has been a busy month in the world of healthcare revenue cycle management with plenty of developments related to new medical codes, prior authorizations, the No Surprises Act, and more. Here’s a roundup of 10 newsworthy stories to share with physicians and staff in your medical practice.
1. CMS adds utilization data for 6 new procedures to the Medicare.gov website
The specifics: When patients and others use the Medicare.gov compare tool, they can now access utilization data for these 6 new procedures: Upper endoscopy, arthroscopy (upper extremity), arthroscopy (lower extremity), varicose vein ablation, laminectomy/laminotomy (lumbar), and lower limb revascularization.
Why it matters: These procedures are part of a growing list that will likely continue to expand over time. In January 2024, CMS added the first procedure volume data file with information for 12 procedures.
What’s next: Familiarize yourself with the Care Compare Initiative so you’re aware of what data patients may be able to access about you and the care you provide.
2. Clinical lab fee schedule updates coming October 1
The specifics: Several new lab codes take effect October 1 while others will be deleted, according to a recent MLN Matters article.
Why it matters: Reporting accurate billing codes helps avoid denials and ensures revenue integrity.
What’s next: Familiarize yourself with the changes to determine whether any of them affect your medical practice.
3. American Medical Association and others urge congressional leaders to focus on the sustainability of medical practices
The specifics: The American Medical Association (AMA), all 50 state medical societies, and 76 other healthcare organizations recently wrote a letter to congressional leaders outlining the importance of policy reform to preserve patient access to care and improve care quality. The letter focused on these 4 areas of reform:
- Enacting an annual, permanent inflationary payment update in Medicare that is tied to the Medicare Economic Index
- Budget Neutrality reforms
- An overhaul of MACRA’s Merit-based Incentive Payment System
- Modifications to Alternative Payment Models
Why it matters: The fiscal sustainability of today’s medical practices is a dire issue in healthcare. The AMA and others say the current Medicare Physician Payment System is increasingly unsustainable and that necessary policy reforms can no longer be delayed.
What’s next: Stay tuned for updates or contact the AMA for more information.
4. AMA reminds physicians that coders, billers can enter medical codes in the patient’s record
The specifics: In this recent article, the AMA debunks the myth that only physicians can physically enter or change medical codes in a patient’s health record. The truth is that coding and billing specialists can enter or change diagnosis and procedure codes to ensure compliance and match the services provided. However, these changes must be a joint effort between physicians and their RCM teams.
Why it matters: Coding and billing specialists well-versed in coding guidelines can help medical practices promote revenue integrity and avoid leaving money on the table.
What’s next: Identify the current role of coders and billers in your medical practice and determine whether it might be beneficial for them to assign all medical codes or validate physician-assigned codes prior to claim submission.
5. Medicare Advantage plans under scrutiny for prior authorization denials
The specifics: In 2022, more than 46 million prior authorization requests were submitted to Medicare Advantage insurers, according to recent data. That same year, insurers fully or partially denied 3.4 million (7.4%) prior authorization requests. The vast majority of appeals (83.2%) resulted in overturning the initial prior authorization denial.
Why it matters: This data suggests that patients may endure unnecessary care delays for medically necessary services. Appeals also add administrative burden and costs.
What’s next: Know what is (or isn’t) happening within your state, and advocate for change. Note that many states have already passed legislation aimed at cutting the volume of prior authorization requirements, reducing care delays, and increasing publicly reported data.
6. Physician pays more than $600K to resolve False Claims Act case
The specifics: A Tulsa, Oklahoma-based physician recently paid $619,994 to resolve allegations he submitted claims for performing services while he was out of the office and traveling.
Why it matters: Regardless of whether it’s intentional or unintentional, healthcare fraud has serious financial, legal, and reputational implications.
What’s next: Conduct ongoing revenue cycle audits to ensure compliance.
7. Patients increasingly interact with artificial intelligence (AI) to find health information
The specifics: A third of the public, and nearly half of younger adults, say they use or interact with AI at least several times a week, according to a recent poll. However, most adults are not confident that health information provided by AI chatbots is accurate.
Why it matters: Misinformation in healthcare is a significant challenge, and the onus often falls on physicians to set the record straight.
What’s next: Be prepared to answer patients’ questions and provide accurate health information. Also think carefully about any AI tools you use in your medical practice to ensure those tools promote information integrity.
8. ICD-10-CM Coordination and Maintenance Committee Meeting coming up soon
The specifics: The ICD-10-CM Coordination and Maintenance Committee Meeting will be held September 10-11, 2024. Up for discussion? Forty ICD-10-CM topics.
Why it matters: This annual meeting is a public forum to discuss proposed changes to ICD-10-CM. This is your opportunity to weigh in.
What’s next: Consider joining the meeting via Zoom. Registration is required at: https://cms.zoomgov.com/webinar/register/WN_8hiZrGNcQYCFuH9P7LCloQ. The Meeting ID is 160 744 0104 and the passcode is 621302. While you’re at it, be sure to review the new, revised, and deleted ICD-10-CM codes for fiscal year 2025 that take effect October 1.
9. Adverse childhood experiences (ACE) fuel higher healthcare utilization and expenditures
The specifics: A recent study found that adults with ACEs had substantially higher utilization and 26.3% higher expenditures when compared with demographically similar adults without ACEs. There are also associations between ACEs and a range of adverse adult circumstances such as financial and housing problems, social network problems, little or no life satisfaction, stress, food insecurity, verbal abuse, physical harm, and discrimination.
Why it matters: This research suggests that ACEs are associated with large societal costs in the form of increased healthcare spending.
What’s next: Researchers advocate for policies that change how providers screen for ACEs and treat exposed children and adults. Stay tuned for new and emerging work in this important area.
10. No Surprises Act complaints yield to consumers and providers
The specifics: As of June 30, 2024, CMS received more than 16,000 complaints related to the No Surprises Act, according to a recent report. The agency resolved 12,077 of these complaints, resulting in approximately $4,183,383 in monetary relief paid to consumers or providers. The primary issues for providers involve surprise bills and discrepancies in good faith estimates.
Why it matters: The volume of complaints and associated financial implications are significant. These numbers could continue to increase as consumers become more aware of their legal rights.
What’s next: Take a look at compliance within your own medical practice and familiarize yourself with No Surprises Act requirements.
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