By Dr. Benjamin Barlow, chief medical officer, Experity.
As we evaluate the healthcare landscape following the COVID-19 pandemic, particularly the urgent care (UC) industry, facilities have undergone significant transformation. Patient behaviors and economic factors have converged to reshape the way people perceive healthcare.
For urgent care, access to the use of reliable, accurate data is critical to inform intelligent decision-making and clinic success throughout dynamic market conditions and changing consumer preferences.
Part of this adaption centers around redefining expectations and benchmarks to measure success by leveraging data-driven insights to ensure that UC clinics continue meeting the evolving needs of their patient population.
Changing Patient Behaviors
In 2019, urgent care clinics were a familiar and reliable part of the healthcare ecosystem. Patients sought their services for minor injuries, illnesses, and a range of non-life-threatening conditions. During the pandemic, patients visited for COVID-related issues like testing, vaccinations, and respiratory care, but were hesitant to visit medical facilities for non-COVID conditions in fear of contracting diseases.
Now, UC clinics are vastly different as patient sentiment has again changed. This transformation can be attributed to shifts in patient behavior and the economic impact of healthcare decisions. Additionally, the end of the public health emergency (PHE) has stripped millions of Americans of their Medicaid coverage, further amplifying the issue of healthcare access, and adding to the uncertainty surrounding patient healthcare coverage.
According to a 2022 Gallup report, 38% of Americans delayed seeking medical care due to cost implications, marking a 12% increase from the previous year. This reflects the growing concerns surrounding healthcare affordability, having a profound impact on when and where patients seek medical attention. Rising deductibles, changes in insurance coverage, and the economic conditions following the pandemic have led individuals to reconsider their healthcare choices, often delaying care until conditions worsen and requiring costly emergency room (ER) visits.
The worsening of these cases is often preventable if patients seek care when they first notice symptoms, and UCs can help fill this gap as an alternative to an ER visit. With robust education through marketing initiatives, the value of a practice and the services it can provide throughout the community will ensure patients have the information needed to make educated decisions about their healthcare.
Oftentimes, medical facilities need to focus on preventing overstock and out-of-stock supplies needed to get their work done or when needed to provide their patients with the best care. But like any other business, sometimes, those much-needed items such as tools, supplies, or even something such as a medical file are temporarily misplaced and become lost until someone just by chance finds it again.
This clearly destroys productivity for everyone involved; you’re missing much-needed items, you’re missing information and issues that need to be solved have to be placed on the back burner until something is found again or needs to be reordered. There’s no room for these productivity killers in the workplace, especially in the healthcare sector, where a patient’s health is at risk. Plus, there’s potential for financial loss and compliance issues, too. So, what steps could a health business take to prevent losing medical supplies, tools, files, or anything else? Where? Here’s what you need to know.
You Have to Start By Implementing a Robust Inventory Management System
When it comes to any business, whether it’s in the healthcare industry or not, you’ll have to focus all on this first. Essentially, the foundation of preventing medical supply loss is a well-organized inventory management tool system. So, it’s best to go ahead and implement an electronic inventory tracking system that allows you to monitor stock levels, track usage, and set reorder points for critical supplies. Plus, you’ll also want to regularly update and reconcile your inventory to ensure accuracy.
Oftentimes, medical facilities need to focus on preventing overstock and out-of-stock supplies needed to get their work done or when needed to provide their patients with the best care. But like any other business, sometimes, those much-needed items such as tools, supplies, or even something such as a medical file are temporarily misplaced and become lost until someone just by chance finds it again.
This clearly destroys productivity for everyone involved; you’re missing much-needed items, you’re missing information and issues that need to be solved have to be placed on the back burner until something is found again or needs to be reordered. There’s no room for these productivity killers in the workplace, especially in the healthcare sector, where a patient’s health is at risk. Plus, there’s potential for financial loss and compliance issues, too. So, what steps could a health business take to prevent losing medical supplies, tools, files, or anything else? Where? Here’s what you need to know.
You Have to Start By Implementing a Robust Inventory Management System
When it comes to any business, whether it’s in the healthcare industry or not, you’ll have to focus all on this first. Essentially, the foundation of preventing medical supply loss is a well-organized inventory management tool system. So, it’s best to go ahead and implement an electronic inventory tracking system that allows you to monitor stock levels, track usage, and set reorder points for critical supplies. Plus, you’ll also want to regularly update and reconcile your inventory to ensure accuracy.
External payer audits quadrupled in volume in 2023, making timely responses more challenging than ever for resource-strapped healthcare organizations. Though patient volumes and surgeries have begun to recover from COVID-19 declines – with a 23% and 27% increase over 2022 – inflation, staffing shortages, reimbursement, and regulatory issues continue to jeopardize the financial health of healthcare organizations nationwide.
These were among the key findings of the 2023 MDaudit Annual Benchmark Report released today by MDaudit, an award-winning provider of technologies and analytic tools that enable the nation’s premier healthcare organizations to minimize billing risk and maximize revenues.
Ritesh Ramesh
“Increased complexity and reduced resources mean healthcare organizations are operating in an environment that demands flawless optimization for billing compliance, coding, and revenue integrity capabilities,” said Ritesh Ramesh, CEO of MDaudit. “Our analysis reveals the urgency for healthcare systems to stay ahead of the curve by harnessing digital initiatives and advanced technologies, including AI, machine learning, and analytics, to proactively manage compliance and revenue risks.”
Beyond technology, healthcare leaders must break down the silos between teams to create cross-functional/departmental synergies and manage change to stay operationally efficient. This will be imperative for growth and profitability going into 2024.
Shrinking Teams Face Growing Compliance and Revenue Integrity Challenges
Amidst nationwide healthcare staffing shortages, technology, automation, and analytics have emerged as critical catalysts for health system executives to drive change. Leaders are leveraging these tools to boost productivity, generate revenue, and control costs while compensating for reduced staffing levels. Managing denials and ensuring timely payments are important, but even more crucial is understanding and addressing the root causes of issues that start upstream with billing and coding practices in provider operations.
Across the MDaudit customer base, there was an increase in technology-driven productivity. Large auditing teams were able to accomplish 10% more in audit activities compared to 2022 with more or less the same resources.
Medicare Advantage plans were under constant scrutiny from the Federal government for compliance and overpayments. The data shows that these plans rejected 25% more in reimbursement dollars to providers this year versus 2022.
Telehealth remains a substantial contributor to compliance and revenue challenges. According to MDaudit data, telehealth volumes were flat relative to last year and an average of 30% of audits failed for services administered in a patient’s home or office. Proficiently coding and documenting these crucial charges is imperative for ensuring the ongoing success of patient care and favorable outcomes.
In 2023, external payer audits surged fourfold compared to 2022, often involving large audit documentation requests (ADRs). Mounting requests with tight deadlines and appeal timelines posed a significant risk of revenue loss and potential clawbacks, creating challenges for hospitals because of staffing issues.
Mitigating Denials to Protect Revenues
MDaudit’s findings emphasized the crucial role revenue integrity and billing compliance play in supporting the accurate and ethical capture and optimization of revenue for services rendered to patients. These teams are crucial for preserving financial stability, sustainability, and compliance, all while upholding the commitment to delivering high-quality patient care. Billing and coding are not about revenue alone; these cross-functional workflows directly influence patient experience and relationships, as well as a healthcare organization’s ability to grow.
Health systems are burdened by denials and increasing demand, underscoring the vital need for operational efficiency in billing, coding, and clinical documentation to enhance profitability.
The MDaudit analysis also found that:
Commercial payers are taking longer to respond to claims in 2023 vs 2022. Initial response times were 29 days (about six business weeks) for an outpatient claim and 35 days (about seven business weeks) for an inpatient claim.
MDaudit data for 2023 shows the value of commercial payers’ initial denials for professional claims has increased by 30% and by 5% for inpatient claims, as compared to 2022.
Medicare Part A and Part B rejected 16% of the claims initially submitted for outpatient services – the most profitable for healthcare organizations.
More than 60% of professional billing claim denials in 2023 were driven by documentation requests and eligibility concerns from payers.
“As we move into 2024, proactive actions and precision on billing compliance and revenue integrity outcomes are no longer optional. The healthcare landscape is evolving, affecting every facet of this industry,” said Ramesh. “New payer strategies and the integration of AI have intensified denials, payment delays, and claim scrutiny. How organizations and providers adapt and respond to these challenges will shape their long-term success.”
About the Report
The MDaudit Annual Benchmark Report equips compliance, HIM/coding, revenue integrity, and finance executives with industry insights, emerging trends, and data-driven information to help them take informed action and enhance outcomes for their organizations. The analysis in this report includes a comprehensive examination of data collected from a network of over 650,000 providers and more than 2,200 facilities that provide data to MDaudit for auditing, charge analysis, and denial assessment. This report encompasses insights from more than $5 billion in audited professional and hospital claims and denials by both commercial and government payers exceeding $150 billion.
If you were to believe all the headlines you read about AI in healthcare, you’d probably think that AI will be curing cancer and replacing doctors within the year. I mean, there have certainly been some exciting advancements. For instance, medical teams at MIT and Mass General Cancer Center recently developed and tested an AI tool that was able to look at an image and accurately predict the risk of a patient developing lung cancer within six years.
On the other hand, Elizabeth Holmes, the founder of Theranos, stands as a prominent example of what happens when people blindly believe the hype about healthcare and technology. Her fraudulent claims about a supposedly revolutionary blood testing technology raised concerns about the oversight and regulation of AI and healthcare innovations, and ultimately ended with her being sentenced to eleven-years in prison.
To make the most of AI without getting blinded by the hype, I recommend treating it like any other new technology: subject it to rigorous scrutiny, demand transparency, and emphasize responsible implementation. AI isn’t a magic wand that will instantly cure all ailments or replace the expertise of medical professionals. It’s a tool – a potentially powerful one – but it’s still just a tool.
Which medical fields benefit most?
Some fields of medicine will benefit from using AI more than others. For instance, the field of medical imaging and diagnostics has already seen the benefits of AI. Again, radiology departments can now utilize AI algorithms to analyze medical images such as X-rays, MRIs, and CT scans. These algorithms can identify abnormalities and assist radiologists in making more accurate and timely diagnoses.
Another field that will benefit from AI is drug development in pharmaceuticals. Scientists can use AI to analyze massive datasets of molecular structures and predict potential drug candidates. This is much more efficient than having organic chemists sift through datasets by hand. AI can also expedite clinical trial recruitment by matching eligible patients with suitable trials based on their medical records. So, AI can accelerate drug discovery, reduce research and development costs, and bring life-saving treatments to market more quickly.
Even more human-oriented tasks, such as patient engagement and remote monitoring, stand to benefit from AI. AI-powered healthcare CRM systems can enable personalized patient communication and remote health monitoring. These systems can send automated follow-up messages, answer patient queries, and detect potential issues based on patient-reported symptoms. AI enables enhanced patient engagement, improved adherence to treatment plans, and early detection of health issues. This frees up time for healthcare staff, allowing them to focus on more complex tasks.
Autonomous coding enjoys a high level of trust among healthcare finance professionals who use or plan to use the technology, with 45 percent indicating it often works well and 16 percent placing complete trust in it. Yet despite its emergence as a powerful tool for streamlining and improving error-prone manual coding processes, autonomous coding suffers from an awareness problem, with 52 percent saying they do not know what it is.
Those are the findings of a new survey from the Healthcare Financial Management Association (HFMA) on behalf of AGS Health, a leading provider of tech-enabled revenue cycle management (RCM) solutions and strategic growth partner to healthcare providers across the U.S. More than 450 healthcare finance professionals were surveyed during the 2023 HFMA Annual Conference on their knowledge of and value expectations for autonomous coding, including 60 percent that use or plan to use autonomous coding.
More than half (52%) of respondents said they don’t know what autonomous coding is and 30 percent either did not or were unsure if it could be trusted.
Thomas Thatapudi
“Despite high expectations around its potential to increase coder productivity and coding accuracy, reduction in denials, missed charges and low-risk scores, and accelerated provider decision-making, autonomous coding suffers from a knowledge gap that must be closed if we are to see broader adoption,” said Thomas Thatapudi, CIO of AGS Health. “Until we can fully educate finance leadership on the potential autonomous coding holds for improving the healthcare revenue cycle, we are unlikely to see an acceleration in use cases for AI-powered technology which includes autonomous coding.”
Among the key benefits of autonomous coding is its ability to eliminate the potential for human errors that result in missed reimbursement opportunities, backlogs, delays, and claims errors, and its ability to push accuracy levels to near perfect percentages. All of which can be achieved in near real time with the right integration pipelines. Autonomous coding is also faster than its human counterparts – it can complete charts in seconds – yet it also understands what it does not know, flagging it for human review.
Accidents can be confusing and scary, whether they’re small accidents or big ones. When accidents happen, it’s not just the physical pain that people have to deal with; they also have to navigate the complicated world of healthcare.
While it might seem easier to let the experts handle everything, it’s important for accident victims to take an active role in their recovery. This means understanding their rights when it comes to medical care and the potential compensation they may be entitled to. For those who want to know about compensation, learn more about personal injury law here.
Here are the seven essential healthcare rights that every accident victim should know.
Right to Timely Medical Care
Right after an accident, getting medical help as soon as possible is super important. Even if the injuries don’t seem too bad at first, some problems might not show up until days later. Getting medical help quickly makes sure that any potential issues are found and treated early, which reduces the chances of having long-term problems. Plus, it can make a difference in compensation for legal actions later because it shows a clear connection between the accident and the injuries.
Right to Choose the Healthcare Provider
Even though insurance companies might suggest certain healthcare providers, accident victims don’t have to use them, and a legal attorney can help assert this right. Picking a healthcare provider they trust ensures that they get fair and impartial care. Also, the records and documents from the chosen provider can be important when talking to insurance people or making a case in court. It’s your health, so you should have a say in who takes care of you.
Right to Informed Consent
Medical procedures can be scary, so doctors have to explain everything to the patient before any treatment begins. This means telling them exactly what will happen, what the risks are, what other options are, and what could happen. Being well-informed lets victims confidently make decisions so they’re never in the dark about their healthcare. It’s all about making sure you have a say in what happens to your body.
By Andy McDonald, vice president of operations, Salucro.
Every profession has its own ‘bucket list’ — a collection of goals that people aim to achieve during their career. For revenue cycle leaders in healthcare, their bucket list items tend to center on strategic objectives designed to modernize the healthcare financial experience, enhance the patient experience, and streamline operations.
As vice president of operations at Salucro, a payment technology company exclusively focused in the healthcare space, I talk to clients, partners, and revenue cycle leaders every day and these are five of the most common priorities I hear:
Upgrading and Consolidating Revenue Cycle Tools
With the complexity of modern health systems comes a continuous influx of new technologies designed to optimize revenue cycle management. But the key to truly reaping the benefits of these advancements lies not in simply adopting the latest tool on the market, but in integrating and streamlining these solutions into a single, efficient system.
Patients have also begun to recognize the digital shift in their financial experience, with 93% saying they expect healthcare providers to use more and more technology to collect payments, according to a recent report.
The integration and consolidation of tools can dramatically improve the productivity of your staff. When they are spending less time navigating multiple systems, rectifying errors, and piecing together data from different sources, they can focus more on enhancing the patient financial experience and other high-value tasks that cannot be automated.
Improving the Patient Financial Experience
The patient experience encompasses all touchpoints of a patient’s journey, from the first call to schedule an appointment to the final payment transaction. Patients expect and deserve a seamless, intuitive, and personalized experience at each of these touchpoints – and with 50% of patients stating that their last billing encounter was bumpy, painful, or confusing, the quality experience that providers strive to offer doesn’t always carry throughout the full patient journey.
Leveraging technology can greatly enhance the patient experience. According to a 2023 survey of healthcare consumers throughout the U.S., 62% of patients pay their bills by credit or debit card via an online patient portal. These digital platforms not only cater to the modern patient’s preference for online interactions, but also help to improve revenue cycle efficiency.
Revenue cycle tools can automate patient communications, ensuring that patients receive timely billing notifications and follow-up messages. Survey data shows that patients are responding positively to these tools, as 51% of patients said a text message reminder would prompt them to pay their bill faster.
