Financial/Revenue Cycle Management

Geisinger, University of Utah Health and other leading health systems to test winning designs in the contest called A Bill You Can Understand, sponsored by AARP.

Michael Middleton, MD, credits online patient portals with helping him grow his Orlando, Florida-based pediatric practice more than three-fold in two-and-a-half years – while keeping staff cost increases at 20 percent.

Four years after what Black Book calls the "replacement frenzy," a recent survey from the market research firm indicates that 87 percent of financially struggling hospitals now regret changing their EHR systems. Among the difficulties the survey highlighted were higher than expected costs, layoffs, declining inpatient revenues, disenfranchised clinicians and doubts over the benefits of switching systems. The survey, which polled 1,204 hospital executives and 2,133 IT staff users, found that 14 percent of all hospitals that replaced their original EHR since 2011 were losing inpatient revenue at a pace that wouldn't support the total cost of their replacement EHR. "It was a risky decision as hospitals were facing the fact that they would not be back to their pre-EHR implementation patient volumes, inpatient or ambulatory, for at least another five years," said Doug Brown, managing partner of Black Book, in a statement. [Also: 'Dissatisfaction' leading to EHR replacement trend] "No other industry spends so much per unit of IT on the part of the business that is shrinking the fastest and holds little growth as did inpatient revenues," he said. Other key findings Black Book gleaned from its survey: 62 percent of non-managerial IT staff says was a significantly negative impact on healthcare delivery directly attributable to the EHR replacement initiative; 90 percent of nurses indicated the EHR process changes diminished their ability to deliver hands-on care at the same effectiveness, yet only 5 percent of hospital leaders indicated EHR replacement had impacted care in a negative way. "In our experience polling, most executives will not admit they were oversold or that their IT decisions had adverse bearing on patient care," Brown noted. Black Book also found that hospital EHR replacements cost jobs, and levels of interoperability decreased. Also, EHR sales people exaggerated the automatic buy-in of physicians and other clinicians, according to Black Book findings.

In the first major overhaul of Medicaid managed care requirements in more than a decade, the Centers for Medicare and Medicaid Services published new rules on April 25 that affect how Medicaid works for the nearly two-thirds of beneficiaries who get their coverage through private managed care plans. It aligns key rules and practices with those of marketplace and Medicare Advantage, including the addition of reporting medical loss ratio to Medicaid to ensure managed care plans focus on delivering care, not profits, CMS said. The rule finalizes a medical loss ratio at 85 percent. Insurers must spend at least 85 percent of their Medicaid revenue on medical care to improve quality. The remaining 15 percent may be spent for administrative reasons such as salaries and marketing, CMS said. Health plans that don't meet the goal will face future penalties in having their state rates lowered. On the health information technology front, the rules encourage – but don't require – commitment to the principles of health information exchange "Health information technology and the electronic exchange of health information are important tools for achieving the care coordination objectives proposed," according to the final rule. HHS "supports the principle that all individuals, their families, their healthcare and social service providers, and payers should have consistent and timely access to health information in a standardized format that can be securely exchanged among the patient, providers, and others involved in the individual’s care," it states.   "Further, the Department is committed to accelerating health information exchange through the use of health IT across the broader care continuum and across payers. Health IT that facilitates the secure, efficient and effective sharing and use of health-related information when and where it is needed is an important contributor to improving health outcomes, improving health care quality and lowering health care costs." Specifically, the rule points to ONC's Nationwide Interoperability Roadmap and 2016 Interoperability Standards Advisory as containing the "best available standards and implementation specifications to enable priority HIE functions." Providers, payers, and vendors are encouraged to take them into account "as they implement interoperable HIE across the continuum of care, including care settings such as behavioral health, long-term and post-acute care, and community service providers." CMS also sets the conditions for broader applications of telehealth, specifically as a way to bolster network adequacy standards. "Several commenters recommended that CMS add elements (to the rule) to include triage lines or screening systems, as well as the use of telemedicine, e-visits, and/or other evolving and innovative technological solutions," officials write. "We agree with commenters that such services and technological solutions could impact the needs of enrollees in a particular area and could change the manner and extent to which other network providers are needed and utilized. We encourage states to consider how current and future technological solutions could impact their network adequacy standards." An estimated 72 million Americans currently rely on Medicaid as their source of health insurance coverage, 14 million more than in 2013, CMS said. This is largely due to the Affordable Care Act's coverage expansion. The improvements modernize the way managed care health plans operate so that Medicaid and CHIP continue to provide cost-effective, high quality care to consumers, according to Monday's announcement by Andy Slavitt, CMS acting administrator and Vikki Wachino, CMS deputy administrator and director for the Center for Medicaid and CHIP Services. The rule strengthens states' efforts to support delivery system reform and authorizes the first-ever Medicaid and CHIP quality rating system so that states can publicly report plan quality information, and people can use that information to select plans, CMS said. The rule also addresses quality of care standards, as well as focusing on improved communications, such as electronic notices to beneficiaries and creating online provider directories. "States are making gains in using population based payments, episodes of care and quality-based payments," write Slavitt and Wachino in a blog post. "In addition, states operate 30 health home programs that focus on coordinating care for people with chronic conditions like obesity, diabetes and mental health conditions. Over the last several years, sates have undertaken significant efforts through State Innovation Models, integrated care models, and delivery system reform incentive programs to create alignment with physicians and hospitals to provide the highest quality of care. And we have proven that when we and states dedicate ourselves to changing the delivery of care, we get results." Read the final rule here.

Here’s the rub: $50 billion might be hyperbole, but $5 billion is still a sizable enough market to drive innovations that health systems can harness to engage patients, better manage populations and ultimately improve care and the bottom line.    

Healthcare executives indicated a positive outlook for 2016, with 71 percent expecting their revenues to increase this year, according to a new survey.

Centra Health announced on Thursday that it will deploy Cerner Millennium on both the clinical and business sides, including revenue cycle and patient health management. Centra will also implement HealtheIntent, Cerner’s population health management platform. In addition, Cerner will support Centra’s growing health plan, which covers more than 45,000 individuals. With five hospitals and 50 ambulatory and long-term facilities, the Centra is one of the largest healthcare systems in central Virginia.   [Also: How satisfied are you with your EHR? Satisfaction Survey results] “As one of the leading care providers in our area of the country, it is essential that Centra continues to influence the health of not only our patients, but also our community as a whole,” CEO E.W. Tibbs Jr., said in a statement. Financial terms of the deal were not revealed. Twitter: @Bernie_HITN Email the writer: bernie.monegain@himssmedia.com Like Healthcare IT News on Facebook and LinkedIn

Revenue cycle management has gone from being a "back office" function to an "end-to-end" system that begins at patient intake or even before, claims specialists say. Advanced technologies, in tandem with improved workflows and better data have resulted in RCM systems that encompass the entire healthcare enterprise. With the right automation tools and revenue cycle support, experts say healthcare providers should be able to improve their cash flows by collecting patient payments up front, determining precise eligibilities and filing clean claims to payers. With the fee-for-service business model changing to prospective payment and value-based care, healthcare organizations are undergoing a cultural shift that dramatically alters their approaches to patient intake, eligibility verification and claims processing. These are issues that providers will have to understand and adjust to accordingly, says Jose' Rivera, vice president of physician solutions development at Santa Rosa, Calif.-based Visiquate. "Fee-for-service is going away and bundled payments will come to fruition," he said. "We will see a resurgence of capitation because it puts the risk back on the provider. Organizations were able to overcome ICD-10, but as the model moves toward quality I think we'll see another resurgence of value proposition payer mixes." As a result, Rivera believes it will be a lot more difficult to get paid. Meeting the challenge means physicians must become educated on tracking quality metrics and reporting them to payers, he says. "This is a formidable task because different payers with different contracts all want slightly different quality metrics," Rivera said. "It's a big question mark in the back of my mind." Emphasizing intake RCM specialists agree that patient intake is a critical part of the revenue cycle process and that if they aren't emphasizing it, they need to do so immediately. Collecting patient deductibles, co-payments and eligibility authorizations is paramount for boosting the organization's cash flow as well as for ensuring clean claims, Rivera said. "That is the front line – they need to capture that information correctly and guide it to the right places," he said. "When it comes to authorizations, we are still in a prehistoric environment where a payer has to be called on the phone and it's a half-hour wait to get the authorization. This process definitely needs to be upgraded." Patient registration is undergoing dramatic change, with intake clerks "being asked to do more and more," says Colleen Wood, vice president for the Eastern U.S. at Jacksonville, Fla.-based Availity. RCM technology at the point of intake should be leveraging technology for patient data capture as well as having credit and debit card readers for upfront payments, she said. And while some providers – especially physicians – have been reluctant to ask for payment upfront, collecting deductibles and co-payments at intake fosters cash flow while informing patients of their obligations. "As patients, they should want to know how much it will cost," she said. "This is an opportunity for them to ask about costs and manage their dollars, which they couldn't do previously." Receiving deductibles and co-payments not only improves cash flow, it also creates a more comprehensive patient profile, Wood said. "It goes deeper than just getting deductibles and co-insurance," she said. "It is the total dollar for the patient and provider experience. Deductibles are part of the equation, but the challenge is that there is a ton of data about patients being eligible for services, but also the benefit level each payer covers and how it is going to be covered. Providers need to realize they need to get the total dollar and understanding of the benefit level for every patient, whether it is in the physician or hospital setting." Illuminating the buckets Although the emphasis is on intake, the back end of the revenue cycle continues to be as vital as always and clean claims remain the key to prompt payment. Still, there are stumbling blocks in the claims filing system, says Jay Deady, CEO of Greenwood Village, Colo.-based Recondo. "On the back end, we need to identify the buckets and reasons why claims aren't adjudicated cleanly," he said. "When we illuminate those buckets, patient ineligibility and lack of authorization are still the main reasons for denials." Electronic data interchange transactions with payers is still the standard for eligibility and authorization data, but Deady's research shows that the information can be wrong up to 25 percent of the time. On the whole, however, the process has improved immensely in the past few years, he said. "We're getting more information earlier, getting more information cleared earlier and more is being done earlier," he said. Many moving parts While the end-to-end revenue cycle system has become more automated, there are "still a lot of moving parts" within the process, noted Mike Nissenbaum, CEO of Dallas-based billing contractor Aprima. "There are so many changes just on what is covered and how much will be paid," he said. "There are constant changes in plans and the payers can modify formularies and delay them up to six months. That is very stressful. If we don't pay attention to all these rules changes, our clients suffer." 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The move toward population health and alternative payment models has seen providers embracing innovative approaches to care delivery, including significant investments in health information technology, according to the spring 2016 Economic Outlook survey from Premier. The study – which polled health system chief executive officers, chief financial officers and chief operating officers – found the requirements of the Affordable Care Act and the demands of population health management leading to big changes in care processes. Most notably, Premier found that the expansion and integration of post-acute care networks is a major priority, cited by 95 percent of C-suite respondents as a key area of focus over the next three years. At the same time, almost as many execs said that project is the biggest challenge their health systems will face in the coming years. "As healthcare continues to transition from an acute-care hospital focus toward an integrated system of providers, the creation of high-value post-acute care networks is essential for success within alternative payment models, such as bundled payment programs and accountable care organizations," Premier COO Michael Alkire said in a statement. Health IT, of course, is an essential enabler to this task, and 84 percent of respondents indicated that technology continues to represent a place for significant capital outlay. Still, challenges remain. More than two-thirds (68 percent) of respondents said their health systems are successfully accessing data from the ambulatory EHRs of their employed physicians. But barely one-third (38 percent) said that they're successfully accessing data from affiliated or non-employed physician networks. "Many affiliated practices lack the proper incentives to invest in high-cost data sharing agreements and interoperable interfaces. We urgently need public policies that require health IT interoperability standards so that providers can access data from any system," said Alkire. Interestingly, one area that's often overlooked with regard to pop health is one that's also ripe for innovation, according to Premier: the supply chain. Many providers are running disparate software systems to track procurement, accounting and contract management, according to the report – leading to "system-wide blind spots" that can hamper efficiency efforts. The expansion of affiliated practices have only complicated matters, according to more than half of poll respondents. "By marrying all the functions associated with purchasing across the continuum on a single IT platform, materials managers can close gaps and generate the significant savings needed to succeed in the new world of payment reform and cost cuts," said Alkire.

Some experts are predicting a spike in denials beginning on Oct. 1, 2016 when the Centers for Medicare and Medicaid Services will require claims to be more specific. Forward-looking providers are assembling teams to prepare now.