Guest post by Crystal Ewing, senior business analyst and manager of regulatory strategy, ZirMed.
Crystal Ewing
Denial management is an industry-wide challenge—and despite traditional approaches intended to reduce denial rates, it’s one that continues to grow. Frankly, this is absurd.
I say that because, despite the recent announcements from CMS regarding changes to how they will process ICD-10-coded claims for the first year, denials will likely still increase under ICD-10—and that’s something healthcare providers don’t need to suffer in full, because it is possible to reduce their denial rates before ICD-10. Ultimately this will be more impactful than any denial management program specifically targeting ICD-10-related denials, because the “everyday” denials will otherwise endure and continue to delay A/R long after whatever disruption ICD-10 causes has long faded into distant memory.
Here are two simple truths:
90 percent of denials are preventable
More than 60 percent of denials are recoverable
So where does this leave healthcare organizations seeking to decrease denials ahead of ICD-10, a change that—despite recent announcements from CMS—is nonetheless likely to bring with it a spike in denials?
Exactly where they’ve always been—in need of straightforward best practices that actually help them drive down everyday denials that create A/R delays, back-office backlogs, and an unreliable revenue cycle.
Step 1: Thoughtful Automation
Let’s step through a common process for working denials, just to clarify why it’s such a headache.
Here are some time-study figures—per each denial, staff spend:
4 minutes identifying the denial and routing it appropriately
+ 10 minutes gathering information
+ 30 minutes compiling and filling out appeal letter and materials
+ 5 minutes just documenting all their activity related to the denial
and visit/log in to the associated payer’s website for 25 percent of denials
That is unacceptable—which is an opinion. But it’s also unnecessary, and that’s a fact. Each of the time-consuming manual processes mentioned above can be eliminated or significantly reduced through thoughtful automation and workflow-focused software development.
Reducing research time and enabling staff to easily resubmit denied claims are two of the biggest denial management time-savers—period.
Guest post by Donald M. Burt, MD, Chief Medical Officer, PatientKeeper, Inc.
Don Burt
Many physicians and revenue cycle professionals at healthcare provider organizations are suffering acute ICD-10sion as the calendar flips relentlessly toward October 1.
For all the complexity associated with ICD-10, there are some relatively simple things healthcare providers can do to prepare the front-end of their revenue cycle for the change-over. By “front-end” we mean physician charge capture, the origin of much of a practice’s revenue. The key to success is to make physician charge capture as tailored, flexible, and straightforward as possible for physicians, billers and coders.
A system is tailored when it exposes only relevant codes to physicians in a particular specialty or department, and when it provides fine-tuned code edits. It is flexible when it lets physicians enter charges on the device of their choice – a computer in the office or at home, a smartphone in the car, a tablet anywhere – and when it gives physicians the ability to use familiar clinical terminology to look up codes. And a charge capture system is straightforward when it is seamlessly integrated into physicians’ workflow via the EHR, and into the finance staff’s workflow via the billing system, necessitating fewer clicks, taps and swipes by all users.
An organization that knows this firsthand is Stony Brook University Physicians on New York’s Long Island. This academic practice affiliated with Stony Brook University School of Medicine has 17 clinical departments through which patient care services are rendered and billed.
For a variety of business reasons, the group’s administrative arm, called the Clinical Practice Management Plan (CPMP), implemented an electronic charge capture solution 10 years ago. A return-on-investment (ROI) study of several departments showed that, over a six month period, charges increased by $2.5 million ($5 million annualized) and claim volume increased by 29 percent. Overall, these departments saw a 50 percent reduction in lag days. One department with particularly dramatic results saw its number of claims increase by nearly 70 percent, while the number of coding issues actually declined by six percent. Clinicians can now quickly and easily record charges for services they deliver – at the point of care, in the office, or anywhere in between.
Along the way, Stony Brook CPMP gained valuable insight into the critical elements that make up a successful charge capture system.
The news about ICD-10 continues to divide providers, one way or another, based on whom is asked and as my friends at NueMD have found, many are still unprepared and most don’t want want it to move forward. These are the primary findings of the recently conducted a third installment of the firm’s survey, “Attitudes toward ICD-10” that was designed to measure how healthcare professionals feel about the upcoming transition. In all, of the 1,000 respondents — primarily from small and medium-sized medical practices — the majority said they think there should be no transition to ICD-10.
The following graphics help explain the sentiment toward the new coding standard for clarification:
According to the results of the survey, NueMD’s data suggest that making the switch to ICD-10 will greatly improve provider’s ability to understand medicine, but can “also introduce some serious struggles for practices while they try to maintain cash flow through the transition.”
For example:
Expectations
Moving on to expectations, according to the survey, the majority of respondents said they are either highly or significantly concerned about the transition to ICD-10. The greatest concern remains for the training and education pf staff during the transition, for obvious reasons. However, payer testing and software upgrade costs are not far behind.
Respondents were most concerned about claims processing, with 65 percent saying they are either “highly” or “significantly” concerned with the transition.
Guest post by Alex Tate, digital marketing specialist, content strategist and a health IT consultant at CureMD.
Most conductors are sounding out the last call for passengers to climb aboard the ICD-10 train. Although the trains won’t reach full steam until Oct. 1, 2015, the test runs will commence shortly. You’re probably wondering why passengers have to sit through these test runs, right? This is because the journey will last for at least 10 years, so everyone needs to get accustomed to the environment of this locomotive.
Your practice is the train, you are its railroad engineer, the conductor is your practice manager, but who are the passengers? Surely not the patients; they don’t need to apply the codes, do they? The answer to both questions is no. The passengers are your medical billing software vendors, you clearinghouses, your payers, and most importantly – your billers and coders.
If you haven’t started inquiring if these stakeholders and their systems will be ready before time, you could suffer from huge reimbursement disruptions once claims become dependent on these new codes. However, you still have time to get your engines running, and here’s what you need to do:
Contact your medical billing vendor
The first passenger on your train, irrespective of the number of trolleys you’re carrying, is your practice management (PM) or medical billing software vendor. This is because you need to inquire if your billing software is ready for the new codes. If not, you’ll not be able to get your claims through because they’ll contain defunct codes.
Additionally, you must also inquire if the vendor has a clear mapping process for ICD-10 conversion. If upgrades cost extra, or if you’ll need more training, you should have that in mind beforehand.
Lastly, ask them when you’ll be able to begin internal and external testing using these new codes, and if they have any recommendations for streamlining the process.
On Apr. 23, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule outlining proposed fiscal year (FY) 2016 Medicare payment policies and rates for the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) and the IRF Quality Reporting Program (IRF QRP). The FY 2016 proposals are summarized below.
Proposed Changes to IRF payment policies and rates:
Changes to the payment rates under the IRF PPS. CMS is proposing to update the IRF PPS payments for FY 2016 to reflect an estimated 1.9 percent increase factor (reflecting a new IRF-specific market basket estimate of 2.7 percent, reduced by a 0.6 percentage point multi-factor productivity adjustment and a 0.2 percentage point reduction required by law). CMS is proposing that if more recent data are subsequently available (for example, a more recent estimate of the market basket or multi-factor productivity adjustment) such data would be used to determine the FY 2016 update in the final rule. An additional 0.2 percent decrease to aggregate payments because of updating the outlier threshold results in an overall update of 1.7 percent (or $130 million), relative to payments in FY 2015.
No changes to the facility-level adjustments. As stated in the FY 2015 IRF PPS final rule (79 FR 45872, 45882 through 45883), CMS froze the facility-level adjustment factors at the FY 2014 levels for FY 2015 and all subsequent years, unless and until we propose to update them again through future notice and comment rulemaking. For FY 2016, CMS will continue to hold the facility-level adjustment factors at the FY 2014 levels as we continue to monitor the most current IRF claims data available to assess the effects of the FY 2014 changes.
ICD-10-CM Conversion. In the FY 2015 IRF PPS final rule (79 FR 45872), CMS finalized conversions from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) for the IRF PPS, which will be effective when ICD-10-CM becomes the required medical data code set for use on Medicare claims and IRF?PAI submissions. CMS reminds providers of IRF services that the implementation date for ICD-10-CM is Oct. 1, 2015.
The Workgroup for Electronic Data Interchange (WEDI), the nation’s leading nonprofit authority on the use of health IT to create efficiencies in healthcare information exchange, announced the release of its findings from its February 2015 ICD-10 Industry Readiness Survey. In its March 31 letter to the HHS Secretary, WEDI reported concern with the current level of industry preparedness noting that many organizations did not take full advantage of the additional time afforded by the one-year delay.
“Unless all industry segments take the initiative to make a dedicated effort and move forward with their implementation work, there will be significant disruption on Oct. 1, 2015,” said Devin Jopp, Ed.D, president and CEO of WEDI.
Highlights from the latest survey findings include:
Compliance date uncertainty: Uncertainty around further delays was listed as a primary obstacle to implementation, appearing on more than 50 percent of all responses for vendors, health plans and providers.
Health plan testing: More than 50 percent of health plans have begun external testing, and of these, a few have completed testing. This is a slight improvement from the prior survey.
Vendor product availability: About 60 percent indicated their vendor products were available or they had started customer testing. This is a slight decrease from about two-thirds in the August 2014 survey. However, the number that responded ‘unknown’ decreased from one eighth to just a handful.
Provider testing: Only 25 percent of provider respondents had begun external testing and only a few others had completed this step. This is actually a decrease from the about 35 percent of provider respondents that had begun external testing in the August 2014 survey.
Leading into HIMSS15, TEKsystems, a provider of IT staffing solutions, IT talent management expertise and IT services, highlights results that explore the current state of IT operations at healthcare organizations. The findings identify key objectives and challenges for healthcare IT teams, the skills most needed to meet those demands, as well as expectations for spending and confidence. The data is gleaned from information captured within TEKsystems’ 2013–2015 annual IT forecasts as reported by IT leaders (CIOs, IT VPs, IT directors, IT hiring managers) at healthcare organizations.
Key findings from the data include:
Expectations for IT Budget Growth Decrease in 2015; Yet Confidence Continues to Increase
Fifty-one percent of respondents expect their organization’s healthcare IT budget to increase in 2015, down from 68 percent that said the same entering 2014, and returning to levels seen entering 2013 (52 percent). Thirty-eight percent expect IT budgets to stay the same, a significant increase over 2014 (23 percent) and similar to levels of 2013 (41 percent).
Sixty-four percent are confident in their IT department’s ability to satisfy business demands in 2015, an increase over the 59 and 58 percent that felt confident heading into 2014 and 2013, respectively. Ten percent indicated they are unconfident in 2015, the same percentage as 2014 and down from 2013 (13 percent).
TEKsystems’ Take: Expectations for budget increases began to normalize last year. Following the ICD-10 extension by Congress, IT leaders felt less pressure to seek additional funding to meet those deadlines. Confidence has continued to grow even as budget increases have leveled out, now that organizations have core personnel in place or have developed other plans, such as outsourcing, to address workload concerns.
IT Support Aligns with Business Challenges; Focus Is on Improving Operations and Efficiency
Organizational Challenge
2014 Rank
2015 Rank (% of IT leaders)
Operational issues
2
1 (81%)
Risk management
1
2 (79%)
Revenue
3
3 (67%)
Workforce management
4
4 (59%)
Customer attraction, retention and satisfaction
5
5 (22%)
Over the last three years, operationally focused areas (e.g., improving efficiency, reducing costs, improving existing IT applications and infrastructure, and managing risk) have all been cited within the top five business objectives that most need IT support.
Business Objective
2015 Rank (% of IT leaders)
Improving efficiency
1 (49%)
Reducing costs
2 (42%)
Improving existing IT applications and infrastructure
3 (37%)
Managing risk
4 (34%)
Delivering operational results
5 (29%)
TEKsystems’ Take: Now that healthcare organizations have identified the biggest challenges facing them in 2015, they are working to align IT support priorities to address those challenges. They have laid the foundations for their large IT initiatives and must shift focus to ensure that they are implementing new projects and establishing best practices in a way that allows them to make the most of existing investments. Increasing efficiency and making the most of these implementations will better position them to take on other projects in the future.
Most Impactful Technology Trends Include Business Intelligence (BI) / Big Data, Security, Mobility, Consumerization and Cloud; Expected Spending Increases Mirror These Areas
Over the last two years, healthcare IT leaders listed BI/Big Data, security, mobility and consumerization of IT/BYOD as the top four trends impacting their organizations.
Area of Impact
2014 Rank
2015 Rank (% of IT leaders)
BI / Big Data
4
1 (61%)
Security
3
2 (54%)
Mobility
1
3 (42%)
Consumerization of IT / BYOD
2
4 (38%)
Cloud
6
5 (31%)
The majority of healthcare IT leaders expect to see spending increases in security (70 percent), mobility (61 percent), BI/Big Data (60 percent) and cloud (55 percent).
TEKsystems’ Take: These expectations for spending increases make sense considering that security, mobility, BI/Big Data and cloud are all cited as the most impactful areas and tend to have some interdependencies. These areas play a large part in how healthcare organizations can increase operational efficiency and risk management.
Hands-on Roles Still Most Critical For Success, Also Most Difficult to Fill with Exceptional Talent
“Doers” continue to be cited as the most critical positions for an organization to achieve success. In 2014 and 2015, project managers, help desk / technical support and programmers and developers were cited within the top four roles most critical to enabling success.
Critical Role
2014 Rank
2015 Rank (% of IT leaders)
Project managers
2
1 (51%)
Help desk / Technical support
3
2 (47%)
Programmers / Developers
1
3 (45%)
IT managers
7
4 (40%)
Software engineers
6
5 (37%)
In terms of the most difficult roles to fill, project managers rank as the No. 1, climbing two spots up from No. 3 in 2014. Security (No. 2), programmers and developers (No. 3), software engineers (No. 4) and architects (No. 5) also ranked within the top five most difficult positions to fill. BI (ranked No. 11 in 2013) ranks as the sixth most difficult position to fill, down from No. 5 in 2014.
More than half of healthcare IT leaders expect salary increases for project managers (55 percent), software engineers (53 percent) and programmers and developers (52 percent). Approximately one-third (34 percent) expect increased salaries for help desk / technical support.
TEKsystems’ Take: It’s not surprising that project managers and programmers and developers remain in the top four most difficult positions to fill, as these staff members are in the trenches ensuring that organizations continue to make the most of their IT investments to increase ease of use and efficiency. This value translates into greater expectations for salary increases as organizations seek to retain their developed talent.
Vast Majority Expect Staff Salaries to Rise; More Than Two out of Five Expect Full-time and Contingent Hiring Increases
Seventy-three percent of healthcare IT leaders expect overall IT salaries to increase in 2015. The remaining 27 percent expect salaries to stay the same, with no respondents expecting salary decreases.
Forty-three percent of healthcare IT leaders expect hiring for full-time IT staff to increase, while 52 percent expect hiring to remain the same. Just 5 percent expect to see a decrease.
Forty-two percent of healthcare IT leaders expect hiring for contingent IT staff to increase, while 52 percent expect hiring to remain the same. Only 6 percent expect to see a decrease.
TEKsystems’ Take: As more work is done to make the most of investments in BI / Big Data, security, mobility and consumerization of IT / BYOD, organizations will need to at least maintain their full-time and contingent workforces in order to cultivate efficiency and make progress. While retaining top talent by increasing salaries will be a key tactic, new staff will need to be brought on as projects expand.
“Last year, we saw an early surge in the numbers of healthcare IT leaders expecting to see budget increases due to the overarching mandate to meet the former ICD-10 implementation deadline and to get new healthcare technology initiatives off the ground,” said Ryan Skains, executive director of TEKsystems Healthcare Services. “We are seeing those numbers level out as organizations not only make headway on the projects they have begun, but as they increasingly become confident in their staff’s expanding expertise and ability to meet major deadlines. Moving forward, the focus will be on refining systems and processes to increase efficiency and growth opportunity.”
As significant changes continue to reshape the U.S. healthcare system, The Physicians Foundation – a nonprofit organization that seeks to advance the work of practicing physicians and help facilitate the delivery of healthcare to patients – has identified five critical areas that will have major impact on practicing physicians and their patients over the next 12 months. The Physicians Watch List for 2015 is based on the Foundation’s insights into the medical practice landscape, supported by data from its 2014 Biennial Physician Survey of 20,000 physicians and other Foundation research and white papers.
Consolidation Hits the Gas Pedal
An increased rate of consolidation among hospitals and health systems continues to drive smaller, independent medical practices into larger systems. This trend is adversely impacting competition in regions where consolidation is most pronounced, while increasing costs and reducing patient choice. Rapid medical consolidation is also presenting a challenge to clinical autonomy. According to the Foundation’s 2014 Biennial Physician Survey, more than two-thirds of all physicians (69 percent) expressed concerns relative to clinical autonomy and their ability to make the best decisions for their patients. Since the rate of medical consolidation shows no signs of abating, it is imperative that hospitals and physicians work together to ensure that clinical decisions are being made independent of any bureaucratic or organizational pressures that could potentially affect the integrity of medical decision-making.
External Pressures Strain the Physician/Patient Relationship
An inadvertent effect of medical consolidation and the rising emphasis on valued-based payment models is increasing strain on the physician / patient relationship. According to the Foundation’s most recent Biennial Survey, 80 percent of physicians describe patient relationships as the most satisfying factor of practicing medicine. Yet, factors such as growing levels of non-clinical paperwork and rising administrative and regulatory pressures are leading to an erosion of quality face-time physicians are able to spend with their patients.
In addition, these pressures can also limit physicians’ choices in terms of practice type while increasing the amount of time and resources they must spend on negotiating with payers and vendors. As these regulatory and marketplace forces persist, it will be more critical than ever for physicians to identify ways to work with support staff in order to maximize the amount of quality time they are able to spend with their patients.
