In an era of resource scarcity for many, it’s imperative for healthcare organizations to strategically identify areas of concern unique to them and on a broader spectrum. Healthcare business professionals and clinicians from entry-level departments to the C-suite should have at minimum a risk assessment in these areas and, ultimately, put in place policies and procedures for how to effectively evaluate, monitor, integrate, and promote efficiencies. Here are 10 focus areas (not listed in order of importance) that may impact everyone within your organization in one way or another. The significance of each will depend on your organization, its existing vulnerabilities, and other internal/external factors.
It’s no surprise that risk adjustment made the list; this is a massive financial area impacting the Medicare trust fund, insurance plans, healthcare providers, and consumers — with a growing number of those being Medicare beneficiaries. It’s projected that by 2025 the number of Medicare beneficiaries enrolled in a Medicare Advantage plan will reach the 50 percent margin of all patients with Medicare. With growing popularity in this type of plan, there is compliance risk.
The Office of Inspector General (OIG) has been reviewing health plans that report an increased risk adjustment factor score to Medicare after performing chart reviews. This type of review oftentimes leads to reporting diagnosis codes missed by the provider or never reported. Although this is an acceptable practice, the issue is that the review often does not result in the removal of diagnosis codes that are not supported in the medical record.
Another area of focus is in-home programs, where a nurse or other healthcare professional (typically not a physician) visits the Medicare beneficiary at home and completes a health risk assessment (HRA). What is concerning here is that there is usually no action taken to have the patient see a qualifying healthcare provider to validate those conditions or develop a plan of care.
Both the chart review and the HRA may work to collect and report diagnosis codes that maximize financial gains for the health plans. Healthcare organizations should have in place proper education and training for provider documentation and the criteria for proper reporting of diagnosis codes. This ensures the coding is accurate upfront, improves care quality, and reduces compliance risks.
Payer contracting can be overwhelming and cantankerous. Does your CEO really know what is included in your payer contract? Does your coding manager or director have a seat at the table when contract negotiations are occurring? To yield the most favorable results for your providers and organization, the right people must be present. Language in a contract for downcoding, pre-payment chart reviews, payment reduction for use of certain modifiers (e.g., modifier 25), application of specific condition guidelines (e.g., sepsis criteria), post-payment recoupments, etc., can best be negotiated by the people who work in the space daily.
Let’s review the following statement which may be found in a typical payer contract: “Physician shall comply with the Physician Manual and all applicable policies of Payer, any of which may be amended by Payer from time to time at the Payer’s sole discretion.” Your legal team would probably be the best entity to provide input, clarification, and rebuttal on this statement.
Now let’s examine this statement: “As a standard practice, the Payer will begin using a new clinical code editing software for medical and behavioral products. This software will facilitate accurate claim processing for medical and behavioral claims submitted on a CMS-1500 claim form ….” Who would be the best entity to provide input on this statement?
When it’s time to renegotiate the contract, does your organization utilize denial management data from the health information management team to appeal some of those decisions? Payer contracts include everything from patient eligibility to which services will be covered to overpayment policies; a single individual or group of individuals whose primary responsibilities focus on operations or finance should not be the only one(s) present at the table.
2023 E/M Changes
The 2023 CPT® evaluation and management (E/M) coding and guidelines for outpatient settings change the method for “applying credit” to E/M services. Although we have had a couple of years to get familiar with the new concepts through the introduction of the 2021 E/M Guidelines for Office and Other Outpatient settings, there is still a learning curve.
Training and education are a requirement for medical coders, billers, auditors, and clinicians. Electronic medical record (EMR) systems — including documentation templates, billing workflows, and chargemasters — require modifications.
If you are a provider using a hand-printed document, such as a charge slip or fee ticket, those documents also need updating.
From a financial perspective, utilization analysis of deleted and revised codes is necessary to understand how these new changes may affect your bottom line beginning this year. With any new process, there must be a period dedicated to monitoring and auditing to ensure that the intended change or implementation was successful.
Medicare increased the number of services that could be offered via telehealth from 118 to 264 covered services due to the COVID-19 pandemic. In 2019, there were 840,000 telehealth services billed to Medicare. That number exploded to 52.7 million during the following two years, with a third of those services belonging to behavioral health. The government, commercial carriers, and many others have been working arduously to flush out Medicare fraud and abuse of telehealth services. The OIG has also filed charges against private telehealth companies that were found to have misled Medicare patients or provided kickbacks to healthcare providers during the pandemic.
In reviewing your organization’s past telehealth services, analyze the medical record for the following: Patient consent, documentation of modality used, documentation of time spent during the patient encounter (where applicable), proper modifier usage, correct place of service code, proper licensure or presence of licensure contracts for providers offering telehealth to patients out of state, etc.
The Centers for Medicare & Medicaid Services (CMS) recently released a roadmap for the end of the COVID-19 public health emergency (PHE). Going into 2023 and beyond, most of us have the expectation that telehealth will remain in effect, but what that looks like is up for debate. What is concrete is that the Medicare and state waivers that allowed most providers to offer telehealth services will expire and organizations will need to have a strategic plan in place to make the shift to fewer telehealth services offered while still being able to meet patients’ expectations.
Hiring and retaining top talent has been a significant challenge in recent years. The healthcare industry, like many others, has experienced significant staff shortages as many in the labor force have made the decision to pursue other careers, organizations, or time away from the job market for self-reflection. The time and expense that goes into hiring can easily put a strain on an organization’s budget.
Retention begins within the recruiting process. Don’t hire to merely fill an opening: Consider candidates you are likely to retain. Investing in a strong talent development program will help in attracting top talent. But don’t stop there. To retain top-notch talent, you must first:
- Understand your company objectives (and culture);
- Identify opportunities for upskilling (and reskilling);
- Provide learning opportunities;
- Create an environment that embraces continuous learning; and
- Promote performance coaching.
Also consider the perks and benefits you offer employees. Are you keeping up with the competition? Employees (depending on many factors such as age, geographic location, etc.) may find value in a certain subset of benefits but no value in others. It’s important for your human resources team to think about the dynamics of the current labor market and make the necessary changes to pivot away from any antiquated recruitment processes and offerings that do not yield a return on investment.
The World Health Organization (WHO) defines health equity as “systematic differences in the health status of different population groups.” Health equity assures everyone has access to quality care regardless of their race, gender, beliefs, geographic location, etc., which is crucial in producing the best patient outcomes. Health inequity may directly impact patient care in a negative way and produce unfavorable provider characterization. Improving the health of the most vulnerable populations not only boosts overall health outcomes and social wellbeing, but also strengthens the economy and helps to build a stronger, equitable future.
Scaling down to your specific practice or organization, implementing strategy around awareness of health equity for all employees may help to identify high-risk patients before they become noncompliant. In recent years, we have seen a huge push toward capturing social determinants of health (SDOH). This requires providers to document SDOH in the medical record and report the associated diagnosis code(s). ICD-10-CM provides a host of codes for reporting SDOH. These codes (Z55-Z65) cover everything from deficiencies in education and employment to problems related to psychosocial circumstances. Proper code reporting may help payers allocate resources to address health equity for their plan members. Internally, you can use the data to allocate or divert labor resources to address the needs of patients. Your organization may also consider financial assistance through various means such as diverse payment options, flexible scheduling, coordination with payers and community organizations, and if you are a non-profit organization, charity care.
Training and Education
When organizations begin to tighten purse strings, training and education efforts are often hard hit. In a world of ever-changing rules and regulations, overwhelming government oversight, and increased financial liabilities, however, training and education should be one of the areas that remains appropriately funded. There is significant risk to not offering education and training to clinicians and staff.
Training for clinicians should include topics related to their scope of work, but also topics related to compliance and privacy. New employees should receive in-depth training on an organization’s policies and procedures. Training for staff should also be related to their scope of work. Most healthcare organizations offer mandatory training on topics such as HIPAA, but what about the False Claims Act, Stark Law, Anti-Kickback Statute, transparency rules, and so on?
With the number of changes healthcare has experienced over the last several years, it’s extremely risky for health systems not to have a training and education process in place that promotes learning, engagement, and accountability for all employees. If you have not made regular updates to your education offerings or developed new content in recent years, you are at risk for high error rates in certain areas of operations and/or billing practices.
Mergers and Acquisitions
Mergers and acquisitions (M&As) have been on the rise over the last two decades. Larger hospital organizations are acquiring smaller hospital systems, physician group practices, and diagnostic centers, and even partnering with other large healthcare systems. Between Jan. 1, 2019, and Jan. 1, 2021, hospital groups acquired 4,000 physician practices, resulting in 58,000 physicians transitioning from being independent to becoming hospital employees.
A great deal of consideration and due diligence is necessary in this process to ensure all parties are represented well and understand the fallout that sometimes occurs as a result. Proper analysis of each party’s operating model, financial standing, compliance records, and other key factors will streamline integration.
Hospitals must understand the workflows and payment methodologies in the outpatient setting. A full coding and billing review of a physician group being acquired is an integral component of an M&A. There is also a huge IT component in making sure electronic medical record systems can communicate with each other and there is timely access to information. Physician groups must be keenly aware of compensation methodologies, as many hospitals offer a different pay structure as it relates to work relative value units. Since hospitals typically operate 24/7, staff may have to use vacation time for holidays. There are many downstream effects of M&As, some positive and some that may be perceived as negative.
Also present is the effect on patients. Patients may benefit from being able to access more diverse services (including support, research, and educational opportunities), as well as experience cost savings from not having to travel to multiple locations. On the flip side, hospitals may have more structured policies and procedures in place that patients may view as stringent and unfriendly.
The Department of Justice (DOJ) is looking at the weight and effectiveness of compliance boards. In June 2020, the DOJ updated its Evaluation of Corporate Compliance Programs. Three key questions are posed within the program update:
- Is the corporation’s compliance program well designed? The compliance program should be effective enough to detect and prevent fraud.
- Is the program being applied earnestly and in good faith? The compliance board should have the appropriate resources, processes, risk assessments, and training processes in place to promote a culture of compliance and quickly identify risk areas.
- Does the corporation’s compliance program work in practice? Staff should feel 100 percent comfortable with reporting compliance concerns without the fear of retaliation. A dedicated reporting compliance hotline and/or email should be available and there should be steps in place to thoroughly investigate complaints.
An effective compliance board should be constructed of senior- or management-level employees, led by a compliance officer. The compliance officer should have the resources needed to effectively lead the board. The compliance officer should not have shared responsibilities or roles that conflict with compliance. For example, the compliance officer should not be responsible for medical reviews, payer/vendor contracting, patient services, etc.
Implementing protocols for continued process improvement, performing incremental analysis, and reporting up to the CEO creates a record of true compliance that a DOJ prosecutor or other legal arm may look upon favorably.
Rounding out our list is COVID-19. We all want to put the pandemic behind us, but there is really no way to have a list such as this without mention of the PHE. All health entities should perform internal audits for COVID-19-related activities, including telehealth services, certification, and COVID-19 testing. Another area (non-claim specific) of concern is Payback Protection Program loans. Your organization must be able to account for 100 percent of loans obtained and proper use of those funds.
The pandemic exposed our vulnerabilities in being able to offer services at a high level when a major disruption occurs. By now, every organization should have assessed how they would fare if another pandemic should occur. If you have not performed a risk assessment in this area, make it a top priority.