By Stephanie Jamison (Greenway Health) and Leigh Burchell (Altera Digital Health), Chair and Vice Chair, EHR Association Executive Committee, and Greg Thole (Oracle), Chair, EHR Association Certification Workgroup
Following an in-depth analysis of HTI-2 and the process of drafting comments (available here), the EHR Association has identified several overarching issues, as well as specific concerns related to Insights measures within the proposed rule.
Highlighting the Positives
Before we delve into the negatives, however, it is important to note that we are highly supportive of several of ASTP’s recommendations. One is the proposal to expand the Certification Program to include criteria focused on the adoption and use of certified health IT by both payers and public health agencies (PHAs) to supplement criteria for healthcare providers. Holding all parties to specific and consistent standards and procedures is critical to achieving real end-to-end interoperability.
Greg Thole
Another is the way ASTP has structured the numerous new proposed FHIR API-based required features (e.g., dynamic registration, SMART Health Cards, CDS Hooks, Subscriptions) in a manner that allows developers to re-use the same capability for multiple different use-case-focused criteria. This is a helpful format that allows developers to streamline and avoid duplicating work effort.
Finally, in the context of the Insights requirements, many of ASTP’s proposals demonstrate attentiveness to the questions and concerns raised by the Association and its member companies since the measures were originally finalized in HTI-1 rulemaking. Some of these tweaks to measurement specifications will reduce the burden and make for more consistent and valuable reporting data.
Overarching Concerns
While we do support many elements of HTI-2, there are also several areas of real concern. We’ve raised many of them previously in comments, but they have yet to be adequately addressed by ASTP and other regulatory agencies.
For example, a common refrain in the Association’s comment letters and RFI responses is that compliance timelines and the scope of work in ASTP regulations create significant burdens for all health IT developers, as well as our healthcare provider customers. We delivered this message related to HTI-1, and our members are now devoting extensive resources to compliance—sometimes at the cost of innovation clients have requested.
Yet, as evidenced by the extensive scope of the HTI-2 proposals, ASTP and CMS continue to ignore the significant and serious timeline concerns we’ve voiced for years. CMS programs, such as the Medicare Promoting Interoperability program and Merit-based Incentive Payment System (MIPS), require healthcare providers to use upgraded certified EHR technology effective essentially on the same deadlines set by ASTP for vendors to deliver those updates. This forces developers to deliver compliant solutions significantly earlier than the deadlines officially listed by ASTP and does not allow adequate runway after the deadline for healthcare providers to adopt the updates, potentially compromising a safe and effective implementation process.
External audit volume more than doubled in 2024 over 2023-including higher rates of pre-payment audits-and total at-risk dollars increased fivefold to $11.2 million per MDaudit customer, impacting healthcare provider organizations’ cash flow and exposing them to higher potential denial rates.
Additionally, improvements in revenues and operating margins throughout 2024 were tempered by higher denial rates, including an increase in coding-related denials of more than 125% and in medical necessity-related denials of 75% for outpatient claims and 140% for inpatient claims. These trends highlight the pressing need to overhaul revenue cycle management (RCM) strategies in the coming year.
These were among the key findings of the 2024 MDaudit Annual Benchmark Report released today by MDaudit, an award-winning cloud-based continuous risk monitoring platform for RCM that enables the nation’s premier healthcare organizations to minimize billing risks and maximize revenues. Last year’s report forecast strong volumes for healthcare organizations, the impact of which was constrained by challenges related to controlling costs, improving margins, and seizing opportunities to generate new revenue streams-predictions that held true as operating margins improved by more than 4% against a surge in audits and denials.
Ritesh Ramesh
“Looking ahead to 2025, those same headwinds, along with new risks around timely reimbursement and cybersecurity costs, will impede continued progress toward financial stability,” said Ritesh Ramesh, CEO, MDaudit. “This backdrop of challenges elevates RCM transformation to a strategic imperative for health systems in 2025, with an emphasis on continuous monitoring of financial risk to enable proactive mitigation of issues before they impact operations.”
Payer Behavioral Shifts Send Audits Surging
An increase in external audit volume, coupled with an increase in the average denied amount per claim across professional (~4%), outpatient (~3%) and inpatient (7%) settings, exerted additional financial pressures on healthcare providers. This year also saw a trend in more pre-payment audits. Unlike traditional post-payment audits that can result in clawbacks, pre-payment audits increase denial risks and cause cash flow issues.
Payers also stepped up clinical documentation scrutiny, sending audits surging by 100% over 2023 levels and contributing to a 3-year increase in clinical denials of 51%. To counter this trend, providers must focus on high-value services and ensure that clinical documentation improvement (CDI), billing, coding, and RCM programs are tightly coupled to implement a closed feedback loop from the backend to the mid-cycle to drive efficiencies.
Additionally, the Centers for Medicare and Medicaid Services (CMS) has put Medicare Advantage (MA) plans under the microscope as it continues ferreting out fraud and abuse-efforts that led to a 72% rise in hierarchical condition category (HCC) and Risk Adjustment audits and a 51% increase in total denial amounts for MA plans.
This heightened scrutiny, coupled with more strident authorization requirements and higher denial rates, have many providers rethinking participation in MA plans. At minimum, billing compliance and coding teams should be focused on eliminating improper practices that will lead to heavy fines and penalties. This is particularly critical considering MDaudit findings that more than 25% of providers on average failed audits across both professional (33%) and hospital (23%) care settings.
Over the past decade, credit card spending has more than tripled, leading to billions of dollars in processing fees for merchants. Despite the size of this industry, many find its complexities challenging to navigate. Credit card processors frequently hide and inflate fees, resulting in substantial annual expenses that could otherwise be reduced or eliminated.
Navigating the ever-changing changing landscape of the processing industry and opaque merchant statements can be especially daunting for medical offices. Those without the expertise or resources to review these costs often wind up paying more than necessary. However, it is possible for experts to demystify these fees through a merchant statement analysis to identify potential savings for medical practices.
Eric Cohen
Eric Cohen, CEO of Merchant Advocate, specializes in assisting businesses and medical practices of all sizes—from large medical groups to small clinics—in uncovering hidden fees and optimizing revenue structures without switching processors.
Below are some common questions Eric encounters from medical office administrators and managers about managing processing fees.
Why should medical practices prioritize optimizing their credit card processing costs?
All businesses would benefit from optimizing their processing costs, but for medical practices, this is even more true given their unique challenges. These include costly fees from virtual credit insurance payments, software integration issues, and handling sensitive patient data, which can mean inflated fees, penalties, and a higher risk for security breaches. Medical practices looking to reduce these unnecessary expenses can bring in a third-party consultant or advisor to find hidden fees and potential areas to optimize their costs, ultimately strengthening their bottom line.
How much do credit card processing fees typically cost medical practices?
Credit card processing fees typically cost anywhere from 2.5% to 4.5%, depending on the type of transaction, merchant category, and card used. Since medical practices often handle large volumes of payments, these fees can go unchecked, becoming quite costly. Businesses can save on these fees by understanding and analyzing their merchant statements to identify areas where they are being overcharged and negotiating with their processor.
How can medical practices avoid these processing fees?
Beyond regularly reviewing credit card statements, medical practices can avoid unnecessary fees by regularly updating their practice management software. With critical patches for security and compatibility, delays in these updates can lead to serious consequences, such as HIPAA violations. These violations can result in hefty fines and damage to your business’ reputation. In addition to protecting your reputation, keeping your software up-to-date and compliant protects your business from any penalties that may arise if not all the required data is passed to the processor.
How can medical practices prepare for credit card surcharging?
Practices considering a surcharge program need to be aware of the laws and regulations that vary by state and card network. For example, New York State recently introduced a law requiring businesses to disclose credit card surcharges, limit them to the processor’s fee, and display the total cost including the surcharge or the cash price alongside the card price before checkout. It’s more important than ever for practices to prepare, which can be achieved by knowing what the law requires of your practice in your state, including familiarizing yourself with fee caps and signage requirements. Many states mandate visible signage at the point of sale, with some requiring signage at the entrance to inform customers about surcharges.
By Ben Manning, director of product management, ETHERFAX.
Despite significant progress in health information technology (HIT) and artificial intelligence (AI), many healthcare processes remain inefficient. Administrative workflows are cumbersome and error-prone, and they can lead to serious repercussions, including delayed patient care, clinician burnout, and mounting costs.
Generative AI (Gen AI) is a type of artificial intelligence that creates new content—such as text, images, or even insights—by learning from large datasets. In healthcare technology, Gen AI has transformative potential. It can automate tasks like generating medical summaries, assisting with diagnostic image analysis, or even suggesting personalized treatment plans, thereby saving time for healthcare providers and improving accuracy in patient care.
Additionally, Gen AI can streamline administrative tasks and data analysis, helping organizations manage records, optimize workflows, and enhance decision-making. However, realizing this potential requires a deep understanding of existing challenges in healthcare workflows and a strategic approach to integrating automation into day-to-day operations.
The Ripple Effect of Inefficiencies
Inefficiencies in healthcare workflows are not isolated incidents; they affect a wide range of stakeholders, each of whom bears the brunt in different ways.
Clinicians find themselves overwhelmed by administrative tasks such as charting, billing, and data entry. These tasks, though essential, are contributing to clinician burnout—a significant issue in the healthcare industry. Dealing with inefficient workflows is also leading to lower job satisfaction and higher turnover rates among medical professionals.
For administrative staff, inefficient workflows translate into an overwhelming volume of paperwork and repetitive manual tasks. This not only lowers productivity but also increases the likelihood of errors, which can have cascading effects throughout the healthcare system. The repetitiveness of data entry workflows, compounded by often inadequate compensation, makes it difficult to attract and retain qualified administrative staff.
For patients, inefficient workflows can manifest as longer wait times, delayed diagnoses, and poor patient experience. When administrative or clinical processes are bogged down by inefficiency, patients experience frustration and dissatisfaction. Worse, their health outcomes may be negatively affected by delays in receiving necessary care.
Digitizing workflows without automation tools often perpetuates existing inefficiencies. Too often these workflows fail to optimize and streamline administrative processes, limiting the potential benefits of health information technology. The push to digitize workflows often means repeating the same paper process, but in a digital format; which doesn’t make the process more efficient.
By Rahul Ajmera, SVP of Provider Market, CitiusTech.
Over three years since U.S. healthcare providers and payers adopted new cost transparency regulations designed to make healthcare costs more accessible. While the intent behind these regulations is in empowering consumers to compare prices across various healthcare services and insurance options, many healthcare organizations continue to struggle or are hesitant in achieving full compliance.
This article aims to quickly decode & rethink the importance of price transparency rules for healthcare organizations, with a change in mindset–embracing it not only as a regulatory requirement but also as a pivotal chance for enhancing care services, improving patient experience, and gaining a competitive edge.
Understanding the compliance gap
The journey to compliance has been slow for some either since pandemic-related disruptions or owing to resource limitations. Many organizations still find it difficult to navigate the intricacies of these regulations, which require a comprehensive overhaul of existing data management practices. The process involves consolidating diverse data sets from various systems and ensuring they are structured appropriately for public disclosure–additionally, a demanding skill set from IT, if they are already overstretched. But before we dive into the complexities, it is due to note that if compliance becomes more widespread, organizations may discover new avenues for more than just operational improvements through careful analysis of the data generated, lead to better patient experience and give competitive edge.
Opportunities for improvement
The push for price transparency presents not just challenges but also opportunities. By making pricing data readily available, hospitals and insurers can facilitate better consumer understanding of direct expenses made. Moreover, the new pricing landscape allows organizations to leverage data analytics at a vantage point. By utilizing data-driven insights gleaned from commercial rates that payors are mandated to publish, healthcare providers can identify reimbursement rates in their participation agreements that are too low relative to what other providers are receiving.
Access to the new price transparency data opens opportunities to modernize and expand traditional health data models to incorporate and analyze vast amounts of unstructured pricing data, offering real-time insights and personalized recommendations to consumers. Advanced analytics and Generative AI can be leveraged to optimize supporting documents for claims, and to simplify complex medical billing correspondences, making it easier for patients to understand costs. An established technology known as Knowledge Graphs can be incorporated with Generative AI to link related data points, ensuring that pricing information is not only accurate but also contextually relevant, driving better decision-making for both providers and patients.
By Caroline Hodge, CEO and co-founder, Dimer Health.
The healthcare industry is at a pivotal juncture, with $320 million in Medicare readmission penalties impacting 2,273 hospitals this year alone. These penalties go beyond financial strain, influencing patient well-being and the sustainability of hospital operations. Amid these challenges, AI-driven innovation offers transformative solutions that could change how hospitals manage post-discharge care. The pressing question is: how can healthcare systems better support patients after discharge to reduce readmissions and enhance overall care?
AI-driven solutions are revolutionizing post-discharge care with a proactive, predictive approach that surpasses traditional reactive methods. By leveraging AI-powered predictive analytics and continuous patient monitoring, potential health issues can be identified early, enabling timely intervention to prevent complications from escalating into readmissions. This accurately predictive component is pivotal, as it not only enhances patient outcomes but also eases financial burdens on hospitals, shifting the model from penalty-focused to performance-driven incentives.
Dimer Health is at the forefront of this movement. By combining real-time AI analytics with a dedicated clinical team, Dimer informs a predictive and proactive care delivery system that bridges the critical gap between hospital discharge and full recovery. This comprehensive approach has already demonstrated significant reductions in readmission rates, showcasing a new benchmark for effective, continuous patient care.
As the adoption of AI in healthcare grows, questions about its impact on future policy and reimbursement frameworks come to the fore. Could integrating AI into post-discharge care pave the way for a shift from penalty-heavy models to value-based, patient-centric incentives? Policymakers and healthcare leaders will soon need to assess how these technologies can promote sustainable care models that benefit patients and the healthcare ecosystem.
The implications are substantial. In an era marked by an aging population, escalating healthcare costs, and workforce shortages, AI-enabled care can become a cornerstone of hospital strategy. As healthcare systems start to leverage these capabilities, there is potential for more resilient, patient-focused care models that align with both economic and clinical objectives.
This evolution is about more than technology; it represents a shift toward reimagining patient care, making continuous, personalized support the new standard in healthcare. The question now is how swiftly and effectively the industry can adapt to this promising frontier.
Marchex (NASDAQ: MCHX), which harnesses the power of AI and conversational intelligence to drive operational excellence and revenue acceleration, today announced the phased rollout of its vertical-specific advanced AI solutions for lead identification, lead value assessment, and trending topics discovery.
These innovative AI solutions deliver descriptive, predictive, and prescriptive insights that enable businesses to improve return on ad spend, understand the primary elements driving changes in customer behavior, and increase sales. Launching in Q4 2024, these solutions are tailored for automotive OEMs and dealers, home services, medical, dental, and automotive services.
“As businesses strive to make informed decisions and drive impactful business outcomes, these new AI solutions underscore our commitment to transforming customer data into a strategic advantage.”
Advanced AI Solutions key benefits:
High-Value Lead Identification: Scoring that reveals the highest potential leads.
Industry-Specific Customization: Businesses receive the most relevant, actionable insights.
Data-Driven Decisions: Track trends, optimize resource allocation, and make informed decisions based on comprehensive customer insights.
Marketing Optimization: Industry specific lead and appointment rate models that optimize marketing campaigns to drive high-value leads.
Improved Attribution: Segment target audiences and improve automated bidding using any combination of lead outcome, lead value, and topics.
Understand relevant customer topics: Identify topics and trends that are most important to a successful sale and customer experience.
“Marchex’s industry leading AI solutions provide an unprecedented level of visibility into customer interactions, offering industry-specific context so businesses can better understand lead value and lead outcomes, the topics that matter most to their customers, and how those topics change over time,” said Troy Hartless, Chief Revenue Officer at Marchex. “As businesses strive to make informed decisions and drive impactful business outcomes, these new AI solutions underscore our commitment to transforming customer data into a strategic advantage.”
By Stephanie Jamison (Greenway Health), Chair, EHR Association Executive Committee
It’s been 20 years since 21 of the industry’s leading EHR vendors came together to create the HIMSS EHR Vendor Association in 2004 to accelerate the widespread adoption of EHRs. The new association was also tasked with helping HIMSS establish its strategic direction and official positions on issues related to the EHR and providing input and feedback on the certification process established by CCHIT.
Now called the EHR Association, what started as a bold concept is still going strong in 2024 with a current membership base of 29 companies: competitors working collaboratively to advance health data interoperability, safely embrace new technologies, and improve the quality and efficiency of care. Our initial focus on furthering the initiatives laid out in the Health IT Strategic Framework, released in July 2004 by the Office of the National Coordinator for Health Information Technology (now known as the Assistant Secretary for Technology Policy, or ASTP), has expanded and evolved along with the state and federal regulatory environment.
At the time, founding Chair Charlene Underwood described the establishment of the EHR Association as a historic opportunity to directly impact healthcare delivery in the US, noting in the press release announcing the new association that “EHR technology has proven its ability to make healthcare safer, more efficient, and more convenient for patients as well as providers.
“As EHR vendors,” she continued, “we have a responsibility to our customers to shape the future of interoperability for effective and secure sharing of patient data, and to the nation to promote the widespread adoption of this life-saving technology.”
Today’s health IT market is vastly different from those early years when hospital EHR adoption was 9% and office-based physician practice adoption was 17%. Now, well over 96% of hospitals and 78% of physicians use an EHR, most of which are certified through the ASTP-driven process. In the years since its establishment, many of the EHR Association’s founding member companies have gone through acquisitions or mergers, and new entrants have stepped up.
The Developer’s Voice
The Association’s record of accomplishments since 2004 reflects the health IT market’s evolution. Over the years, we’ve worked to ensure our members’ voices were heard on regulatory and policy issues of critical importance to both EHR developers and the providers using our technologies. We’ve met with policymakers and submitted comments on everything from meaningful use and standards development to the Nationwide Health Information Exchange and TEFCA to the 21st Century Cures Act and, most recently, HTI-1 and HTI-2.
Our efforts weren’t limited to offering recommendations and feedback, however. We’ve held numerous Congressional Briefings over the years, focusing on issues such as the role of EHRs in value-based care and the 21st Century Cures Act, as well as COVID-19 and health IT, information blocking, and social determinants of health and health equity.
We’ve also leveraged our collective expertise to provide member companies with tools to navigate a tumultuous regulatory landscape. This includes publishing the industry’s first EHR Developer Code of Conduct reflecting our members’ commitment to supporting safe healthcare delivery, fostering continued innovation, and operating with high integrity in the market—a commitment we maintain to this day.
Marchex
By Stephanie Jamison (Greenway Health), Chair, EHR Association Executive Committee