Eliminating Revenue Leakage and Compliance Risk With A Unified Approach To Revenue Integrity

Ritesh Ramesh

By Ritesh Ramesh, chief operating officer, Hayes Management.

As we face the third year of the global pandemic, hospitals and health systems are desperate to shore up bottom lines that have been battered by ongoing financial losses projected to exceed $100 billion in 2021. The key to undoing some of the financial damage is optimizing revenue flow and reducing compliance risk, which requires an understanding of the exact driving forces behind the devastating losses.

For many healthcare organizations, the primary problem can be traced to bundling errors, COVID-19 claim denials, and a range of coding issues.

That’s according to Hayes’ inaugural auditing and revenue integrity report, Healthcare Auditing and Revenue Integrity: 2021 Benchmarking and Trends Report, which analyzed more than $100 billion worth of denials and $2.5 billion in audited claims. It found that bundling errors were the top culprit behind the 34% of inpatient hospital charge initially denied in 2021, each with an average value of $5,300. Internal auditors also identified a significant number of concerns centered around disagreements between procedure codes and diagnoses, contributing to 33% of all internal audits containing “disagree” findings.

Understanding the Drivers

The report is based on a review of professional and hospital claims, including current charge and remit data sent to all payer types, audited in the company’s revenue integrity platform, MDaudit Enterprise, during the first 10 months of 2021. It includes more than 900 facilities, 50,000 providers, 1,500 coders and 700 auditors from U.S.-based acute care and children’s hospitals, academic medical centers, healthcare systems, and single and multi-specialty physician groups.

In terms of denial trends, the report identified bundling as the top category for both inpatient and outpatient hospital charge denials – the latter of which had an average value of $585 for each denied claim. The top reason was that the benefit had been included in a previously adjudicated service or procedure. Professional services had a first-time denial rate of 15%, led by claim submission/billing errors and carrying an average value of $283 each.

Under- and over-coding were also identified as problematic. In terms of revenue risk, audits indicate that under-coding created underpayments averaging $3,200 for a hospital claim and $64 for a professional claim. In terms of over-coding, Medicare Advantage plans and payers in particular are under heightened scrutiny for expensive inpatient medical necessity claims, drug charges, and clinical documentation to justify the final reimbursement.

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How To Market to Medicare Patients

Nowadays our lives are engulfed with advertisements from gigantic billboards on the streets to our TVs to pop-ups online. That saturation can make useful information hard to find. Because of this chaotic promotion method, many people stumble upon impractical data instead of helpful information, especially when it comes to their health.

Most of the time, the explanation behind this inconvenience is related to the algorithms that filter the information online. Considering that Medicare is an essential part of someone’s life after reaching 65, reliable and valid information must reach them.

Four Ways to Market to Medicare Patients

According to recent statistics, 42% of Medicare patients have already chosen a Medicare Plan. However, many people still haven’t learned about the benefits of the Medicare Advantage plan. To make Medicare patients’ lives easier, you need a good marketing strategy to reach them. Here are some suggestions for how Medicare Advantage Plans should be marketed to be more visible:

1.    Use Social Media

Many seniors are pretty in touch with technology, most of them having smartphones. They adopted technology and social media (mainly Facebook) because they can keep in touch with their loved ones. Some confessed that they enjoy reading posts online and learning new things. Taking this into account, platforms such as Facebook, Twitter, or other social media platforms are a fitting place to advertise a Medicare Plan in a friendly and subtle way. Another method of promoting a Medicare Advantage program online is through pay-per-click ads, which makes the ads more prominent and gives them higher visibility.

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Ten Medical Aids That Can Make Your Life Easier

Purchasing ASC Medical Equipment Doesn't Have to Be a Pain ...

Losing control of your own life can be a tough thing to overcome, but you can do it. Whether you’re experiencing profound hearing loss or have arthritis, you can find a way to continue doing the things you love. If you want to take control of your life once more, and maybe make it a little easier, too, then this article is for you. We will discuss ten medical aids to make your life easier.

#1: Wheelchairs

If you have a disability that makes walking difficult, then a wheelchair can be an incredible help. Most wheelchairs come with a variety of attachments, including:

The same wheelchair can be used by multiple people, which makes it a great investment. If you or a loved one needs a wheelchair, then you should look into buying one.

#2: Canes and Walkers

If you cannot walk, then a cane or walker can be a great help. In fact, they’re just as helpful to people with injuries as they are to people with disabilities. That’s because they help you to maintain your balance.

Cane – A cane is a long stick that you hold while walking. They are commonly used by people who want to protect their knees when they walk. Walkers – A walker is a wheeled device that you can use while walking. They are commonly used by people with injuries to their ankles, knees, or hips.

If you can’t walk, then you should try one of these devices. They’ll make your life easier, and you’ll feel better while using them.

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TigerConnect Sells Stake To Vista Equity Partners

About Us | Partners | NetsmartTigerConnect, maker of healthcare’s most powerful software collaboration suite, announces it has received a significant strategic growth investment from Vista Equity Partners, a leading global investment firm focused exclusively on enterprise software, data, and technology-enabled businesses. TigerConnect will leverage the partnership with Vista to continue its mission to improve patient care through real-time, contextual communications.

TigerConnect delivers cloud-native Clinical Communication and Collaboration (CC&C) solutions to more than 7,000 healthcare organizations and 700,000 care team members. Its secure, HIPAA-compliant healthcare communication platform and collaboration suite improves both costs and revenue for healthcare organizations while fundamentally delivering better patient care.

TigerConnect has helped thousands of health systems increase care team collaboration and expedite decision-making while minimizing re-admissions and reducing costs. Beyond its foundations as a clinical communications platform, TigerConnect has expanded its suite to include nurse alarm management and event notificationphysician scheduling, and patient engagement solutions, all of which further enable providers to deliver better, safer patient care.

“At TigerConnect, we are laser-focused on improving the care experience for providers and patients, beginning with access to real-time and contextual communication and collaboration throughout every step of the care journey,” said Brad Brooks, co-founder and chief executive officer of TigerConnect. “We believe that Vista’s expertise in partnering with founder-led and market-leading enterprise software businesses, coupled with our shared values, align strongly with our mission to provide advanced collaboration technologies that improve care delivery.”

“In 2010, the notion of a universal communication and workflow platform for healthcare did not exist, and TigerConnect transformed that,” said Andrew A Brooks, M.D., FAAOS, co-founder and chief medical officer of TigerConnect. “Together with Vista, TigerConnect’s vision remains to improve outcomes for patients and enhance the daily lives of physicians, nurses, and everyone involved within the healthcare system.”

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4 Skills You Need To Be A Critical Care Nurse

Working in intensive care unit is often tiring and stressful. Nurses working in the ICU treat patients with critical medical conditions. At the same, the burden of treating a huge number of patients in a single day can wear them out mentally. The ICU provides for a high-stake environment where one minor mistake can lead to disaster. Therefore, it goes without saying that the nurses have to master a few skills necessary for operating under even the most benign ICU circumstances.

What is Critical Care?

Critical care is medical care provided to people suffering from critical injuries and terminal diseases. Critical care often occurs in an ICU or a critical-care unit where patients need twenty-four-hours monitoring so that changes in health conditions may be identified. An extra vigilant staff of nurses overlooks patients who are the most vulnerable. The responsibilities of a critical care nurse include conducting tests, aiding physicians perform medical examinations, preparing and administering treatment, etc.

What do you need to be a critical care nurse?

If you are a registered nurse and aspire to make it into critical care nursing, you need to have the right combination of education and skills to enter this specialized nursing program. The minimum requirement for a critical-care nurse is an associate degree or bachelor’s degree in nursing (ADN), but your chances of landing more lucrative nursing positions increase with a master’s and a doctoral degree.

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Healthcare Information Systems Connecting Patient Care Plans

By Adrian Johansen, freelance writer; @AdrianJohanse18.

Information systems play key roles in healthcare data collection and management. And healthcare providers are increasingly using these systems to connect patient care plans like never before.

For healthcare professionals, a clear understanding of information systems is paramount. Healthcare professionals must understand how to use these systems for patient care plans. That way, these professionals can leverage patient data and insights to deliver exceptional care.

The True Value of Information Systems for Healthcare

Healthcare information systems simplify patient data collection and management. Every day, healthcare professionals generate massive volumes of patient data. Meanwhile, tracking and organizing this information can be challenging for several reasons.

First, healthcare organizations may use disparate systems to store patient data. The systems may provide limited access to this information. They may make it virtually impossible for healthcare professionals to seamlessly retrieve and review patient data at a moment’s notice, too.

Along with using disparate data storage systems, security and compliance issues are present. Healthcare organizations must secure patient data and ensure only authorized personnel can access their information storage systems. At the same time, they must comply with the HIPAA Security Rule. If healthcare organizations fail to do so, they risk exposing patient data to cybercriminals. They can also face compliance penalties.

Information systems represent the future of information technology in healthcare since they address a wide range of data collection and management issues. When used correctly, information systems ensure healthcare professionals can securely and seamlessly access patient data as needed.

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Pros and Cons of AI In Healthcare Industry

Where is AI used today? - Brought to you by ITChronicles

Across sectors, artificial intelligence (AI) has become commonplace. AI helps streamline tasks, improve efficiency, and simplify complicated procedures in medicine. By 2021, Gartner assumes that 75% of these firms will invest in the potential of healthcare AI to enhance their overall performance.

Even with this, others still debate the pros and cons of the clinical and economic implications of relying on data-driven technology and algorithms for patient care, including:

Pro: It saves resources

As more critical activities are automated, medical practitioners will have more time to examine patients and detect diseases.

With the help of artificial intelligence, medical institutions may save time and money by performing treatments more quickly. Furthermore, AI has the potential to save substantial quantities of cash. It’s estimated that over $200 billion is wasted each year in the healthcare business. Many of these wasted expenses may be traced to tedious administrative tasks such as filing, assessing, and finalizing accounts.

Another area for improvement is determining medical necessity. Traditionally, hours of assessing patient history and information are required to establish medical needs accurately. Natural language processing (NLP) and deep learning (DL) algorithms are developed to help clinicians analyze hospital cases and prevent rejections.

Medical practitioners are given more time to help and interact with patients as resources and critical productivity hours are freed up.

Con: Susceptible to errors

Diagnostic data produced from millions of cataloged examples is the foundation of medical AI. A lack of information on specific environmental factors, illnesses, or demography might be misdiagnosed. Whatever the system, there will always be some missing information. There may be a lack of knowledge about particular populations and treatment responses when writing prescriptions.

This incidence may cause difficulties in identifying and treating individuals from particular backgrounds. To accommodate for data shortfalls, AI is constantly developing and improving. However, it’s vital to highlight that it may still exclude some groups from current domain knowledge.

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Trella Health Acquires PlayMaker Health

Referral Marketing StrategiesTrella Health, a leading source of healthcare growth insights and performance analytics, announces its acquisition of PlayMaker Health. The combination allows Trella to infuse its robust, actionable market intelligence and acclaimed customer experience capabilities with PlayMaker’s mobile-first customer relationship management (CRM) offering. Together the companies create the post-acute care industry’s most comprehensive market intelligence, engagement, and growth platform.

“We are thrilled to increase our investment into our customers’ success,” shared J. Scott Tapp, president and CEO at Trella. “Now, they’ll have a single platform to help them focus their strategy, empower sales and marketing, and advance their business. In addition, this acquisition adds a fantastic group of industry experts to our team, while opening the door to new adjacent end markets, including home medical equipment (HME) and infusion.”

On the heels of Trella’s recent growth investment from Cressey & Company and Panoramic Ventures (formerly BIP Capital), the PlayMaker acquisition represents Trella’s first transformative strategic investment. Growing its product capabilities will further support healthcare providers in advancing their organizations with confidence.

“Every post-acute organization needs these critical solutions to understand their market and business today,” said Rebecca Molesworth, VP Product Management at Trella. “Our new combined platform brings more than 40 integrated referral EMR partners to our current offering. And, in turn, we’re eager to introduce PlayMaker’s customers to our industry-leading analytics.”

“The blend of these two solutions is truly a gamechanger for the industry, and I’m looking forward to seeing the impact it will have for post-acute care going forward,” said Gregg Boyle, CEO of PlayMaker Health.”

Brentwood Capital Advisors LLC served as the exclusive financial advisor to Trella. Stifel, Nicolaus & Company, Inc. served as the exclusive financial advisor to PlayMaker.

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Study Rates Every State’s Telehealth Laws For Patient Access

A new report from Reason Foundation, Cicero Institute and Pioneer Institute rates every state’s telehealth policy for patient access and ease of providing virtual care.

Millions of Americans tried telehealth for the first time last year as federal officials and governors temporarily lifted restrictions that limited patient access to virtual care. But many of these restrictions on practices like speaking with doctors across state lines, recording voice messages with care instructions, and mandating insurance coverage have been reinstated, the new report finds.

“Once the public health emergency declarations started to end or executive orders were withdrawn many of the new flexibilities for providers, insurers, and patients were lost overnight,” said Vittorio Nastasi, policy analyst at Reason Foundation and co-author of the report. “States need to adopt a number of telehealth reforms to provide their residents better access to this safe and effective virtual care.”

Nationally, the study finds that several states that have been hardest hit by the pandemic have the most restrictive telehealth laws. These states include New York, California, and Connecticut which have not signed up for interstate licensing compacts and have coverage parity mandates that offer no flexibility between the insurer and provider.

Only three states — Arizona, Florida, and Indiana — allow all providers to easily practice telehealth across state lines. Forty-seven others have arbitrary barriers in place that limit patients’ access to specialists and available appointments based purely on residency.

On a positive note, almost all states have removed the requirement that a patient must first see a provider in-person before they can use telehealth services, the exception being Tennessee, while Alaska and West Virginia require an in-person visit before certain services can be provided. Another 20 states allow full independent practice for nurse practitioners without the supervision of a physician.

The report highlights telehealth policy best practices for states. “While they cannot and should not replace all in-person medical appointments, virtual visits can save patients time and help them avoid germ-filled waiting rooms. Providers can also take some pressure off overburdened systems as they can see patients from an office or home,” writes report co-author Josh Archambault, a senior fellow with Cicero Institute and Pioneer Institute.

The full report with state rankings is available online from Pioneer InstituteReason Foundation, and Cicero Institute.

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What To Look For In Emergency Care

For medical emergencies, options narrow down to a hospital ER or an urgent medical care clinic. Ambulances or other modes of transportation, hospital emergency rooms, or intensive care units may provide emergency care. Examples of emergencies may include chest pain, difficulty breathing, a heart attack, catastrophic injury, uncontrollable bleeding, and a mental crisis.

For instance, visiting a hospital ER is not assuring immediate service. They are prone to very long queues. Compared to an urgent medical care clinic, the wait is barely noticeable.

The hospitals have an advantage over hours of operation, unlike urgent care centers, which are not open throughout the day.

Regardless of your option, specific professional standards should not be overlooked. Many medical emergencies, such as the cold, fractured bones, or headaches, may call for a trip to the nearest emergency care center. As the number of walk-in emergency hospitals grows by the day, how can a patient choose the ideal care center for them?

What To Look For In Emergency Care

Below are some elements to be keen on when choosing an emergency hospital.

1. Location

It comes off as so obvious, but this is a critical consideration. Being close to an urgent medical care center allows for short drives should there be any traffic.

A nearby location has a higher chance of offering to park than a hospital in a busy city. Emergency hospitals near you ensure patient-first values and see that patients can stay close to home without forfeiting the quality of medical care.

 2. Operational Hours

Understanding that emergencies do not pick the perfect time to occur will lead to an urgent medical care center that is open during nighttime hours. Most open during the day from 8.00 am to 5.00 pm.

Be sure not to overlook this factor. A clinic that best suits you should be available around the clock.

3. Professional Care

Whether the attendants at an urgent medical care center are busy, treatment with courtesy should never be questioned. Simple things as greetings, polite and kind words like “thank you” and “please.”

Making eye contact with the patient reassures them it will all be okay. The human touch in urgent medical care centers makes the patient feel more at ease despite their emergency. An emergency hospital of trust and positivity is something to be on the lookout for.

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