Vital Signs: A December 2024 wrap-up of revenue cycle management healthcare news

Welcome to “Vital Signs,” your go-to monthly roundup of all things related to RCM tailored for independent practices and medical billers. Access previous editions for the top insights and developments here.

As we wrap up 2024, December was a busy month for revenue cycle news with stories covering Office of Inspector General (OIG) scrutiny of Office for Civil Rights (OCR) Health Insurance Portability and Accountability Act (HIPAA) audits, a new Centers for Medicare & Medicaid Services (CMS) proposal to expand access to anti-obesity medications and expose Medicare Advantage prior authorization rules, Medicare improper payment rates, and more.

Here’s a roundup of 7 RCM news December 2024 stories to share with others in your medical practice or medical billing company.  

The specifics: In a recent report, the OIG found that the OCR HIPAA audits are too narrow in scope to reduce risks and that the program overall is not effective at improving cybersecurity protections.

Why it matters: As cybersecurity risks continue to increase and evolve, providers and covered entities must adhere to all privacy and security requirements — and OCR must be able to identify vulnerabilities with ease. Without proper oversight, patient information will continue to be at risk. 

What’s next: Per the OIG’s recommendations, OCR will expand the scope of its HIPAA audits to assess compliance with physical and technical safeguards from the Security Rule. It will also define and document criteria for determining whether a compliance issue identified during a HIPAA audit should result in OCR initiating a compliance review. Finally, OCR will define metrics for monitoring the effectiveness of HIPAA audits at improving audited entities’ protections over ePHI and periodically review whether it should refine those metrics. 

The specifics: CMS recently published a proposed rule (CMS-4208-P) that, if finalized, would permit coverage of anti-obesity medications for the treatment of obesity. If finalized, the rule would also make Medicare Advantage (MA) plans’ prior authorization and coverage criteria publicly available. 

Why it matters: Regarding weight loss medications, the proposal reflects CMS’ recognition of obesity as a disease as well as the increasing prevalence of obesity in the United States population generally, and in the Medicare population more specifically. Regarding MA authorizations, MA plans overturn 80% of their decisions to deny claims when those claims are appealed to the plan, meaning inappropriate prior authorization may delay and deny access to care when patients need it. Exposing coverage criteria may help improve access and reduce administrative burden.

What’s next: Comments on the proposed rule are due 5pm EST on January 27, 2025. Stay tuned for additional developments and a final rule.

The specifics: Just 1 day after the CEO of UnitedHealthcare was killed, Anthem Blue Cross Blue Shield (BCBS) announced it would reverse its policy change to pre-determine the time allowed for anesthesia care during a surgery or procedure based on physician work time values. If an anesthesiologist submitted a bill where the actual time of care was longer than Anthem's limit, Anthem would have denied payment for the anesthesiologist’s care. 

Why it matters: The American Society of Anesthesiologists (ASA) say this is another example of insurers putting profits over patients. ASA noted that in June 2024, Elevance Health, the corporate name for Anthem, reported a 24.12% increase in its year-over-year net income to $2.3 billion. It also reported a 24.29% increase in its year-over-year net profit margin.

What’s next: Follow important industry conversations about prior authorization requirements as this and similar stories continue to evolve.

The specifics: This recent article highlights the critical role of telehealth for mental and behavioral health in the context of natural disasters, mass shootings, and civil unrest. It underscores the importance of integrating telehealth into emergency response plans. 

Why it matters: Emergencies happen all too frequently. Telehealth plays an important role in ensuring continuity of care, mental health support, and crisis counseling.

What’s next: If you provide behavioral and mental health telehealth services, be sure to actively document and maintain specific information about local mental health and addiction referral sources, including minority-specific sources. Also consider creating a telehealth disaster preparedness plan so you’re ready when disaster strikes. 

The specifics: A recent study found that by 2030, nontraditional providers could deliver 30% of primary care, with strong growth from payer-owned providers and enabled primary care providers.

Why it matters: These changes will demand creativity and innovation from today’s independent primary care providers. Authors say traditional independent primary care providers may be unlikely to negotiate higher fee-for-service rates moving forward.

What’s next: Authors say providers who want to remain independent should seek partnerships with enablers that can help them successfully transition to value-based payment models. Here’s an article about one value-based reimbursement.

The specifics: Updated in December, this CMS webpage provides information about new codes for advanced primary care management services announced in the CY 2025 physician fee schedule final rule. The webpage defines the services, explains who can bill them and how often, and describes billing requirements.

Why it matters: These codes, which are Healthcare Common Procedure Coding System (HCPCS) codes G0556-G0558, are billable services that can help physicians increase revenue while ensuring patients have access to high quality primary care services.

What’s next: Review the CMS webpage to determine whether you may be able to provide and bill for these important services. 

The specifics: In its 2024 Medicare fee-for-service supplemental improper payment data, the US Department of Health and Human Services (HHS) states that more than half a billion dollars in improper payments were made last year involving Current Procedural Terminology (CPT) code 99214. HHS found that 63.4% of the improper payments involved in 99214’s $564 million in errors last year were linked to incorrect coding. Another 20.1% had no documentation, while 16.5% had insufficient documentation.

Why it matters: CPT code 99214 was the most-billed code submitted to Medicare payers, according to the most recent CMS data (which reflected claims submitted in 2023). 

What’s next: Be sure to thoroughly document every encounter and only submit claims that the medical record supports.