By Edward R. Gaines III, JD, CCP, vice president of regulatory affairs and industry liaison, Zotec Partners.
The limited and under-resourced infrastructure established by the U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services to determine the disputes between physicians and hospitals versus the health plans known as independent dispute resolution (IDR), established under the No Surprises Act (NSA), has been overwhelmed. We also know that a federal judge in Texas has twice adjudicated HHS’ regulations in the past year to be contrary to the NSA statute.
The court ruled in favor of the Texas Medical Association (TMA) on February 6, 2023. It stated that HHS attempted once again to place its regulatory “thumb” on the scales of justice in favor of the health plans, which violated the express provisions of the NSA. The statute authorizes HHS, the U.S. Department of Labor, and the U.S. Department of the Treasury to issue implementation regulations.
Tens of thousands of backlogged IDR adjudications were made worse when CMS announced an immediate suspension of IDR decisions in light of the second TMA court decision. Also, the February 24, 2023, CMS announcement of the restart of certain pending IDRs with dates of service before October 25, 2022 — the effective date of the HHS final rule which was vacated in the TMA II case — will only partially address the tremendous backlog of IDR cases pending final determination by the IDR entity.
There are two additional lawsuits against the administration’s bungled implementation of the “batching rules” and qualifying payment amount calculations (TMA III). The qualifying payment amount is the median allowed amount by the health plan as of January 31, 2019, adjusted for inflation. Additionally, with the exorbitant, nonrefundable, still unaddressed fee increases (TMA IV), there remain many unknowns and issues regarding the resolution of the pending IDRs.
After grossly underestimating the number of IDRs that HHS expected and, in consequence, creating an under-resourced IDR system, the NSA has become extremely costly for the health care system. With millions of dollars tied up in the IDR process, it is particularly devastating for physician practices. Millions more have been awarded to hospitals and physicians; however, based on feedback from clients and industry associations, most insurance carriers, adjudicated as the loser in IDR, still haven’t paid what is owed.
Below is a summary of the many important questions and outstanding concerns that remain unanswered with severe consequences for healthcare physicians and organizations.
There is a huge debate on the topic is the internet, a great source of development and education for young people or is a boon that is responsible for killing all the privacy and security which are one of the most important parts of a service network. There were times when people used to log in to their accounts on other people’s phones and then without even logging them out they used to leave it just like anything.
The concept of cybercafes is one of the most dangerous parts as the person who is using a particular computer in the cyber Cafe is exposed to a lot of privacy and security threats in general known as cyber-attacks. Cyber attacks can be done in many forms and it is not just spam that you receive in your mail ID. As we know that cyber-attacks are at their peak nowadays, and there must be a lot of solutions in the market to prevent cyber-attacks to happen.
Penetration testing is one of the latest technologies for the prevention of cyber attacks.
Black Box Approach:
The main thing about the software which is to be tested and to prevent cyber attacks is that the information about the software must be there for the better prevention of cyber attacks but at the same time in Blackbox approach, the same does not happen. The internal knowledge of the products must be known at the same time while the cyber attack is spoofed. But when we talk about the black box approach, then the same thing is seen to be invalid as the internal knowledge is not present in the product. The behavior of the software and also the attributes of the software at the same time are important but in the Blackbox approach, they both are not known.
White Box Approach:
As discussed before the main thing about the software which is to be tested and to prevent cyber attacks is the information about the software which was not present in the black box approach. But when we talk about the white box approach then it is present and it is a major advantage for this type of approach. When we talk about testing practices, then we must make sure that it is done in the right way and under the system supervision of the developer as he is the source of the software. In the white box approach, the testing practices are done from the perspective of a developer. It is also known as structural testing.
Grey Box Testing:
Grey box testing as the name suggest must be a combination of white and black which in itself when mixed produces grey color. When the white and black colors are mixed, then a grey color is formed and this type of testing method also indicates the same. All the positives of the black box approach or mix with the best positives of the white box approach to give a result as a grey box testing method.
It is no secret that the U.S. has been struggling with a nursing workforce crisis for years, with healthcare organizations recruiting foreign nurses as a quick fix to fill swelling vacancies. During the pandemic, the influx of international nurses from the Philippines, Jamaica, India, Canada, and Africa increased significantly, up 44% from 2021 and 109% from 2018, according to the O’Grady Peyton International Inc. 2021 survey of International Nurses. Expected to continue in 2023, this trend may help to stem our national shortage in the short term but it also adds to nursing shortages felt abroad.
One country where we have seen a large number of nurses coming to the US to practice from is the Philippines. However, this has left the Philippines with a shortage of over 350,000 nurses, many who come to the U.S. for better wages and working conditions, explained Maria Rosario Vergiere, officer in charge for the Ministry of Health. These nurses who are looking to make an important change in their career raise a fundamental question: Is it ethical to take nurses from one country to fill the nursing shortage in another?
The migration of nurses from one country to another also exposes a larger issue: today’s nursing shortage is global, not just domestic. Countries and global nursing organizations need to work together to solve the nursing workforce crisis globally. The International Council of Nurses and the World Health Organization are recognized leaders in addressing the global nursing shortage; however, they need equitable support from all nations to ensure the shortage is addressed from a global perspective.
International nursing challenges
While recruiting internationally trained nurses may seem like a quick fix, it brings with it a host of challenges along with it that are not always immediately clear. One example is that international nurses must pass the NCLEX exam; and they must adjust to cultural and scope of practice differences. CGFNS International, an immigration-neutral, nonprofit organization, assists internationally educated healthcare professionals wanting to live and work in a desired country. They assess and validate their academic and professional credentials, educating them on language, culture, and practice differences (CGFNS, 2023). The work of this organization has been instrumental over the years in helping acute, long-term care, and other healthcare organizations fill vacant nursing positions with foreign candidates.
International nurses have traditionally struggled to pass the NCLEX exam compared to U.S. nursing graduates due to some of the roadblocks they encounter in their move. In 2021, the first-time pass rate for the NCLEX-RN exam was 82.48% for U.S.-trained nurses and 46.48% for internationally trained nurses (CGFNS, 2022). As nurses attempt to pass the exam again, health systems could experience a strain in their onboarding process for them. However, the bar raises in April when the National State Boards of Nursing releases the Next Generation NCLEX exam for RNs and LPNs. The new NCLEX exam, which assesses clinical judgment and readiness to practice for graduating nurses, could adversely impact the already tenuous flow of internationally trained nurses eligible to work in America.
Will nurses trained in foreign countries be able to pass the Next Generation NCLEX examination? Will their scores be better or worse than the results on the current NCLEX exam? Only time will tell what impact the test changes will have on the international nurse pipeline.
Investigational medicines are drugs or treatments not approved by the U.S. Food and Drug Administration (FDA) for use in the general population. For many patients, especially those with serious illnesses or conditions, these investigational medicines can offer hope when other treatments have failed or are unavailable. However, navigating the process of requesting an investigational medicine can be complicated and intimidating, but it doesn’t have to be. Here is a step-by-step guide to help you understand what you need to know before submitting an application for an investigational medicine.
Understand Your Rights as a Patient
According to the FDA, every patient has the right to access experimental treatments if they meet certain criteria and their doctor agrees it is appropriate for them. It is important to note that while your doctor may agree that an investigational medicine may benefit you, they may not be able to get it approved by the FDA or insurance company due to medical necessity criteria or budget constraints. As such, you need to understand your options before deciding whether or not to pursue investigational medicines.
Research Clinical Trials and Compassionate Use Programs
The most important step is to research clinical trials and compassionate use programs that might be available to you. Many websites, such as ClinicalTrials.gov or Drugs@FDA, provide information on current and upcoming clinical trials related to your condition. If you qualify for a clinical trial, contact the study coordinator on the website to inquire further.
Suppose there are no suitable clinical trials available. In that case, you should explore compassionate use programs offered by pharmaceutical companies or doctors approved by the FDA to give expanded access to drugs outside of clinical trials. Contacting these entities directly is often necessary to gain access if no other options are available.
By Isaac Smith, healthcare content strategist, Medcare MSO.
If you are involved in the healthcare industry, you must be familiar with the terms “ASC Coding and Billing” and “Physician Medical Billing.” These two concepts are important to understand if you are a healthcare provider or if you run a healthcare facility. In this article, we will discuss the differences between ASC Coding and Billing and Physician Medical Billing.
Medical billing and coding are critical components of the healthcare industry. They are the processes that ensure that healthcare providers get paid for their services. Medical billing and coding can be complex and challenging, especially if you are not familiar with the terminologies involved. In this article, we will simplify the concepts of ASC Coding and Billing and Physician Medical Billing.
Starting January 1, 2008, the CMS publishes annual updates to the list of procedures an ASC can be paid for. To establish payment indicators and rates for newly created Level II HCPCS and Category III CPT Codes, CMS updates the lists of covered surgical procedures and ancillary services quarterly. ASC billing and coding are explained below.
On the CMS website, you can find the complete lists of ASC-covered surgical procedures and ancillary services, the applicable payment indicators, payment rates before regional wage adjustments, wage-adjusted payment rates, and wage indices.
ASC certification and a CMS agreement are required for this provision. ASCs must accept Medicare’s full payment for ASC services. Physicians and anesthesiologists can bill and be paid for professional services.
Lab services and non-implantable DME can be billed using the correct certified provider/supplier UPIN/NPI. The basics of ambulatory surgery center billing are simple, but physician and facility requirements differ. Physician and facility billing are different from ASC billing. ASC billing and coding don’t focus on a medical specialty like physician medical billing, which must follow a few highly specialized guidelines to get reimbursed.
ASC Coding and Billing
ASC stands for Ambulatory Surgical Center. An ASC is a healthcare facility where surgeries that do not require an overnight stay are performed. ASCs are becoming increasingly popular because they are less expensive and more convenient than traditional hospital settings. ASCs have their own set of codes and regulations that are different from those of physician medical billing.
ASCs are reimbursed for their services based on a fee schedule set by Medicare. The fee schedule is based on the geographic location of the ASC, and the complexity of the surgical procedure. The fee schedule is also updated annually to reflect changes in the costs of providing healthcare services.
ASCs have their own set of codes that are used to bill for their services. These codes are different from those used in physician medical billing. ASC codes are more specific and detailed, as they are designed to describe the unique services provided in the ASC setting.
Running a healthcare facility, whether a hospital, clinic, or medical practice, requires efficient management to ensure the highest level of patient care while controlling costs. In today’s fast-paced healthcare industry, healthcare leaders face unique challenges that can impact the efficiency and effectiveness of their facilities.
Therefore, this blog explores practical tips to help healthcare facility managers streamline operations, optimize workflows, and enhance patient outcomes. Whether you are a seasoned healthcare professional or new to the industry, these tips will provide valuable insights on running a healthcare facility efficiently.
1) Focus on Staff Development
Providing ongoing training and development opportunities for staff is essential to ensure that they have the knowledge, skills, and ability to deliver quality care. Staff development programs can increase staff engagement, job satisfaction, and retention rates, improving patient outcomes and reducing recruitment and turnover costs.
You should also deliver staff development programs such as the following.
Cross-training can be particularly effective in healthcare, as it allows staff to develop new skills and work in different areas of the facility.
Leadership training is also essential, as it can help to develop strong, influential leaders who can motivate staff, improve processes, and drive innovation.
Continuing education is critical to ensure that staff stays updated on the latest trends and best practices.
Mentorship programs can provide staff guidance, support, and career advancement opportunities.
2) Use Technology
One of the most significant technological advancements in healthcare is healthcare artificial intelligence (AI), which has proved to be a powerful tool in improving patient outcomes and reducing costs.
There are several ways to use healthcare AI to improve the efficiency of healthcare facilities, as listed below.
Implementing electronic health records (EHRs) allows healthcare providers to access patient information quickly and easily, reducing the need for manual data entry and paper-based records. EHRs also enable providers to track patient progress, monitor medication adherence, and identify potential health risks.
Telemedicine allows patients to receive care remotely via video conferencing, chatbots, or other digital platforms. Telemedicine is particularly useful in rural areas or for patients with mobility issues, reducing the need for travel and wait times.
Machine learning algorithms can analyze large datasets to identify patterns and correlations that humans may miss, leading to an earlier and more accurate diagnosis. AI-powered diagnostic tools are already used for conditions such as skin cancer, retinopathy, and pneumonia.
Wearable devices and remote monitoring systems can continuously monitor vital signs and other health metrics, alerting healthcare providers to potential issues before they become serious.
3) Establish Clear Communication
Effective communication channels among staff, patients, and their families to ensure everyone is informed and up-to-date. With clear communication, patients can be more involved in their care, staff can work together more effectively, and potential issues can be addressed before they become significant problems. You can foster clear communication through regular meetings, training, messaging systems, and other communication tools.
4) Monitor Performance
Monitoring performance is vital to measure key performance indicators (KPIs) such as patient satisfaction, wait times, and staff turnover to identify problem areas and track progress over time. Regularly monitoring these KPIs will help healthcare facility managers make informed decisions and take necessary actions to improve the quality of care provided.
You must also set achievable performance targets and align them with the overall mission and goals of the facility. You can track these targets with a dashboard or scorecard to visually represent the facility’s performance in different areas.
Comparing your facility’s performance with others can also provide valuable insights into best practices and areas for improvement.
Staff should also be involved in the performance monitoring process by providing regular feedback and suggestions for improvement. This step can create a continuous culture of improvement and accountability, leading to better patient outcomes and higher staff morale.
5) Manage Finances
Financial management can help healthcare providers streamline operations, improve patient care, and maintain profitability. Below are a few tips for managing finances in a healthcare facility.
Develop a budget and stick to it. So, forecast expenses and revenues and identify areas where you can reduce costs.
Negotiate with vendors and suppliers to obtain the best prices for equipment and supplies and explore bulk discounts.
Healthcare providers should establish effective revenue cycle management (RCM) processes to ensure timely and accurate billing and collections. RCM involves monitoring key performance indicators such as days in accounts receivable, denial rates, and net collections and implementing strategies to improve these metrics.
Healthcare providers should regularly review their financial performance and adjust their strategies accordingly. Thus, you must analyze financial statements and reports, identify trends and patterns, and develop action plans to address any issues.
6) Implement Infection Prevention Aand Control Measures
Infections acquired in healthcare settings can have severe consequences for patients, including prolonged hospital stays, increased morbidity and mortality, and increased healthcare costs. Below are some effective infection prevention and control measures.
Promote proper hand hygiene through education, and provide hand sanitizers and hand washing stations.
You can improve environmental cleaning and disinfection by using effective cleaning agents, standardized cleaning protocols, and routine auditing.
The appropriate use of PPE, such as gloves, masks, and gowns, can be reinforced through education and training programs, and by ensuring that PPE is readily available and properly fitted for staff.
Conclusion
Running a healthcare facility efficiently requires careful planning, effective communication, and a commitment to continuous improvement. By implementing the tips discussed in this article, healthcare providers can improve patient outcomes, reduce costs, and stay competitive in a rapidly changing industry. Ultimately, success in healthcare requires a dedication to excellence, a willingness to adapt to new challenges, and a steadfast commitment to providing high-quality care to those who need it most.
My father was diagnosed with diabetes when he was very young and lived his entire life maneuvering various healthcare systems. He had multiple eye surgeries, which is common for diabetes patients. He had pancreatic issues, open heart surgery, and two kidney transplants. It was a lot and, as his daughter, one of the most difficult parts of it all was watching my mother be his primary caregiver, managing doctor appointments, medication prescriptions, treatment plans and insurance claims.
At the time, there was little to no technology on the practice management side of healthcare. Until the internet connected us all, EHR systems were contained to inpatient and outpatient facilities, primarily used as data interchange platforms for claims processing with scanning capabilities to create images of documents. I remember my mother carrying a binder from doctor’s office to doctor’s office – the most effective way for her to keep an easily accessible list of my father’s ailments, healthcare conditions, medications, and all the other details needed by the countless doctors across my father’s continuum of care.
How AI is creating more meaningful patient experiences
Fast-forward two decades and we’re now in an entirely new reality with an ever-expanding healthcare technology ecosystem. Medical office software platforms do so much more than claims processing and digital document storage. Interoperable EHR systems let physicians share treatment plans and easily access medical histories and lab results anywhere and anytime. Patients can schedule appointments online and login to patient portals to get test results in real time. Telehealth has ushered in brand new healthcare delivery models and helped drive greater adoption of behavioral health services. Remote patient monitoring (RPM) technologies have been a game-changer for so many, helping patients better manage chronic illnesses.
And now, with the integration of artificial intelligence (AI), we’re seeing the next wave of healthtech – an advancement that is bringing our entire industry closer to the promise of fully connected or interoperable healthcare systems. AI is having a massive impact on medical practice workflow processes, empowering healthcare providers and medical office staff. AI applications are making it possible to automate tedious and redundant tasks so that medical professionals can focus their time on valuable work that greatly improves the patient experience and outcomes – and that’s just on the business side of things.
The healthcare sector is predicated on protecting all sensitive information for a practice and its patients. Threats come from every direction, whether through email, an attachment, a malicious link, or simply the penetration of a security system.
Solutions are aplenty but with various degrees of effectiveness and durability, not to mention complexity and quality of protection for the practice, all are important factors when measuring benefits versus risk. As healthcare practice leaders attempt to mitigate their continuous onslaughts of threats, possible breaches, and potential bad actors, automating security measures can alleviate trouble, distractions, and chaos caused by a breach or other malicious activity.
While most in healthcare don’t like to discuss the ugly but open secret, email is a significant factor in many data breaches. Therefore, advanced levels of protection for Outlook and other email servers are essential, and add-on solutions solve the problem of misaddressed emails and prevent data leakage.
Technology that scans for sensitive keywords, personally identifiable information (PII), or data patterns inside the email body or attachments can provide practices with a critical layer of security.
Confirm External Recipients and Attachments
Using data loss awareness (DLA) technology, users can confirm the practice’s external recipients (those receiving a message from the practice) before messages are sent. Such an integrated solution “asks” whether everyone on an email recipient list should be seeing the sensitive information contained, so the message is not sent to someone by mistake. Likewise, this prevents misaddressed emails or inadvertent auto-fill email mistakes.
Email breaches from accidental data loss can result in fines, regulatory non-compliance notices, and even litigation for a medical practice. Additionally, medical practices can (and should) seek solutions that proactively help users to prevent accidental data loss and keeps all sensitive information from leaving the organization
In such environments, all settings should be configurable and specified on a per-user or per-group basis. In addition, healthcare organizations should automate activity logs for all potential occurrences with a complete audit trail stored locally or centrally and supporting Outlook local languages, as these are often needed should you be audited.
