Revenue Cycle Management

AdvantEdge solutions include medical billing, certified coding, analytics,
practice management, compliance and ClientFirstTM service.

Revenue Cycle Management

AdvantEdge solutions include medical billing, certified coding, analytics, practice management, compliance and ClientFirstTM service.

2022 Healthcare Cybersecurity Predictions look a lot like 2021, but with more risk on all fronts. More attacks, more vulnerabilities and more need to prepare. If cybersecurity isn’t in your 2022 plans, or you want to test your 2022 plan, below we offer 3 key steps to take. But first, consider the lessons from 2021.

2021 Healthcare Cybersecurity Lessons

Cybercriminals are particularly partial to the healthcare industry with its abundance of payment information and sensitive personal data that can be sold on the black market. Healthcare companies – along with companies in all industries – are looking for comprehensive strategies to avoid a repeat of 2021. Here is the “tip of the iceberg” for what hit the healthcare industry in 2021 (most ransomware and other cyberattacks are never reported; only PHI breaches are required to be reported).

  • Florida Healthy Kids Corporation: One of the largest ever healthcare data breaches was reported by the Florida-based health insurer Florida Healthy Kids Corp. The Department of Health and Human Services’ Office for Civil Rights was notified that the protected health information (PHI) of up to 3.5 million people may have been compromised.
  • In September 2021, data breaches were reported by HIPAA-regulated entities based in 25 states. Texas was the most affected state with 6 reported breaches of 500 or more records, followed by California with 5 breaches and Connecticut with 4.
  • DuPage Medical Group:  In August 2021, the Illinois-based physician group notified 600,000 patients that their personal health information was exposed when the computer network was hacked in July.
  • Memorial Health System: Hive ransomware was reportedly linked to this attack. The health system was forced to shut down its IT system during the attack and had to divert ambulances and patients to other hospitals during a weeklong outage. 

3 Essential Healthcare Cybersecurity Strategies for 2022

No business or practice is immune to cyberattacks, even smaller ones. In fact, small and midsize businesses represent 60% of attacks! That’s why it’s important to have and implement an all-inclusive cybersecurity strategy.  The three steps below work together to help keep your data safe – and all are essential. The good news is that if you have a solid program in place to protect PHI, as required by HIPAA, your program may just need some fine tuning. But if your HIPAA program is stale, now is the time to rejuvenate it with cybersecurity risks in mind.

1. Well Trained:  The best cybersecurity healthcare strategy is likely to fail without a well-informed and well-trained team. Most breaches start when an employee clicks on a link in an email or provides information over the phone to a hacker. Given the sophistication of cyber criminals, it’s easy to see how an employee can be misled. The only solution, as one organization that was hacked said, is to “have every employee be paranoid about security.”   This means you need staff (or consultants on retainer) with cybersecurity expertise to develop a comprehensive employee training program and who are readily available to answer questions or address concerns. Be sure to appoint one senior person to oversee these efforts.  What’s more, these programs must be updated on a regular basis because cybersecurity is forever evolving. Cybercriminals are constantly inventing new ways to access valuable data. There is a high price to pay if you fail to keep your employees aware of the current cybersecurity healthcare environment. The average cost of a data breach has been reported as almost four million dollars!

2. Think Hard about Software: All healthcare organizations use and rely on technology.  But when it comes to cybersecurity, the importance of having the most current and sophisticated software is crucial to protecting your organization. Check with your software provider to secure the latest software updates and to find out other ways to keep your data safe, including upgrading to newer computers. Antivirus software is essential to protect all devices from viruses, malware, ransomware, spyware and phishing scams.  It’s also important to implement strong password requirements and have experts available who can spot phishing and email scams. Although the learning curve can be steep –  if the right software isn’t already in place – there is simply no option if you want to minimize cyber risks.

3. Vet Vendors: When it comes to third-party vendors, it’s difficult to control precisely who has access to the data you share. That’s why it’s crucial to make sure the vendors you choose take HIPAA security compliance seriously and – best case scenario – are SOC2 and/or HITRUST certified. Among other requirements, these certifications indicate that a vendor has been fully educated in techniques to circumvent data breaches. Without this type of assurance, you risk creating a “weakest link” in your cybersecurity. While it’s necessary to interact with third-party vendors, it’s also essential to do your homework and choose only reputable partners.

2022 Healthcare Cybersecurity Predictions

As in 2021, but to an even greater extent, all practices and departments are vulnerable to cyber attacks, data breaches, ransomware and more. Most attacks and breaches won’t make the news. But that doesn’t reduce their impact. Firms that aren’t prepared will incur substantial costs and potential public embarrassment or worse. Firms that are well prepared are less likely to be attacked and, even if they are, will suffer much less damage.

Practices and departments that work with AdvantEdge eliminate the risks from internal billing systems and reduce billing related data breaches. And they can rely on AdvantEdge systems and procedures built to keep PHI and other client and patient information safe and secure. The latest antivirus tools are in place, strict training keeps employees current on risks, data is always encrypted, AdvantEdge systems limit the data each employee sees to that needed for their specific function and much more.   For almost ten years, AdvantEdge has been certified annually for HIPAA and HITECH privacy and security as well as SOC 1 Type 2 and SOC 2 Type 2 for information security and transparency.

  

Resources

https://medium.com/geekculture/cybersecurity-in-2022-growing-concern-with-greater-opportunity-8a49828e00d5

https://www.hipaaguide.net/florida-health-insurer-discovers-breach-of-the-phi-of-3-5-million-individuals/

https://www.hipaajournal.com/september-2021-healthcare-data-breach-report/

https://chicago.suntimes.com/business/2021/8/30/22649201/dupage-medical-group-notifying-patients-data-breach

https://www.beckershospitalreview.com/cybersecurity/fbi-warns-of-hive-ransomware-after-memorial-health-attack-in-ohio.html#:~:text=FBI%20warns%20of%20Hive%20ransomware%20after%20Memorial%20Health%20attack%20in%20Ohio,-Hannah%20Mitchell%20%2D%20Wednesday&text=The%20FBI%20issued%20a%20warning,a%20result%20of%20the%20attack.

To make 2022 Healthcare Predictions, we start with the lessons and trends from 2021, most notably the Covid-driven disruptions. Of course, the questions practice and department leaders want to answer include

  • Will 2021’s big fluctuations in patient volume continue into 2022? 
  • How long will the Omicron spike last?
  • How bad will cost increases be?
  • Can I find enough workers?
  • What else do I need to worry about/plan for?

2021 Healthcare Trends

2021 Healthcare Utilization Trends

Most practices survived the massive COVID downturn in 2020 only with government subsidies; even then, some went out of business. Those that planned on a return to “normal” in 2021 got a rude shock. 

For example, the Bureau of Economic Analysis found that spending on health services (hospital and ambulatory care) was 7.1% below what would have been expected in June 2021. 

Early 2021 Data Show No Rebound in Health Care Utilization

While volumes picked up somewhat after June, most data show patient volumes remaining below pre-pandemic levels, especially for non-Covid hospital admissions and surgeries. Outpatient and ambulatory volumes have fared only slightly better. Of course, there were wide variations across specialties and geographies, with some practices reporting volumes at or above 2019 levels. 

2021 Healthcare Cost Trends

On the cost side, the news hasn’t been much better. The Provider Relief Fund (PRF) kept many practices afloat in 2020 and in early 2021. But PRF money is all but gone at this point. At the same time, costs have been increasing, especially for technology and labor (average compensation increased by over 4% from 3Q 20 to 3Q 21). And costs are the tip of the iceberg: with almost 20 percent of healthcare workers quitting their jobs since the pandemic started, many practices have lost critical skills, support and even leadership. Total healthcare employment is down by over 450,000 workers since the beginning of the pandemic! (See 2022 Healthcare Workforce Predictions for more details).

Inflation has become a real factor in the second half of 2021 affecting supplies, equipment and salaries. Overall, the annual inflation rate in the US accelerated to 6.8% in November of 2021, the highest since June of 1982.

2021 Healthcare Regulatory Trends

The first part of 2021 saw many regulatory changes still on hold due to emergency Covid exceptions. As the year evolved, some rules that were relaxed earlier, for example around telehealth, were put back into effect. In areas like MIPS / QPP, changes continued to be small.

The debate over 2022 Medicare rates was resolved only after Congress got involved with yet another “quick fix.” See Final Medicare Physician Billing Rates for 2022 for the details.

The regulations that got the most attention in 2021 were those implementing the No Surprises Act, intended to prevent so-called “surprise billing.” See 5 Things to Know About the No Surprises Act for more background.

2022 Healthcare Predictions: the Perfect Storm

As everyone knows, healthcare in 2022 will be heavily influenced by COVID trends, especially with the Omicron variant spreading rapidly at the beginning of the year and COVID hospitalizations spiking in over 30 states. 

  • If Omicron really is less severe than Delta, consumers may continue their “return to normal” behavior. In that scenario, many will need to catch up on deferred care and may drive volumes above pre-pandemic levels as the year unfolds. 2022 Healthcare Predictions
  • At this point in time, that looks like an optimistic scenario. It appears more likely that we will see “rolling waves” of (mainly Omicron) COVID during the first quarter to half of 2022.

    • In this scenario, most hospitals will be overloaded by COVID for at least a few months. That is already the case in parts of the country.
    • As a result, many elective procedures and many screening appointments will be postponed or simply not done.
    • If Omicron peaks quickly during each “wave”, as now seems likely, then the second half of 2022 should see a return to “normal.” Probably sooner in areas hit by Omicron first.

At the same time, practice costs are expected to increase even faster than in 2021 with labor shortages and supply chain disruptions two of the biggest drivers. 

Of course, other factors are also contributing to the 2022 “storm.”

  • PRF and other subsidies will not be available as a cushion in 2022.
  • Medicare reimbursement is set to drop by an average of 2 percent, more for some specialties. See “Final Medicare Physician Billing Rates for 2022” for the details.
  • The macro-economic environment is volatile, with inflation a major risk factor.
  • With the advent of the No Surprises Act, commercial payers are becoming more aggressive in contract negotiations. (See 2022 Surprise Billing Predictions: Lower In Network Fees & More Paperwork for the specifics). 
  • Many patients are not seeking care due to concerns about cost. A December survey indicates that nearly a third of Americans skipped care in the past three months over cost concerns! 
    • A recent Kaiser Family Foundation poll found that, even for insured Americans, nearly half (46%) report difficulty affording their out-of-pocket costs, and one in four (27%) report difficulty affording their deductible.
  • Cybersecurity threats, including ransomware, will continue to increase (See 2022 Healthcare Cybersecurity Predictions and 3 Steps to Take Now for more specifics).

How to Plan for a Stormy 2022?

Facing highly uncertain demand, rapidly increasing costs and other risks, practices need to find ways to navigate the “perfect storm” that COVID has created. There are a number of steps needed to prepare for 2022.

  • Retaining clinical staff will be critical and will require a combination of increased compensation, flexibility, training and recognition. 
    • This is doubly important where staff have been taxed by COVID overload and/or backlash. 
    • The ability to flex clinical staff will become more important. Options include more flexible work hours and arrangements (valued by younger workers and parents, especially women, with children at home), overtime and part-time staff. These options will also help recruit new clinical staff.
    • See 2022 Healthcare Workforce Predictions for more suggestions.
  • Managing costs will be essential since they are likely to increase faster than rates. Overhead costs are an obvious target since salaries and benefits will need to remain competitive. Finding more efficient workflows that improve productivity should be another focus.
  • Where remote care is possible, practices should develop or expand their offers to patients. Remote Patient Monitoring and even Critical Care Monitoring are expected to expand rapidly. Many of these options can be added quickly by partnering with the right service provider.
  • Your privacy and cybersecurity plan needs to be enhanced and updated, unless the plan is fresh. See 2022 Healthcare Cybersecurity Predictions and 3 Steps to Take Now for specific suggestions.
  • Make sure you have the proper notices and patient cost estimate procedures in place to meet the No Surprises obligations. See No Surprises Impacts All Physicians in 2022 for the specifics.
  • If you have favorable in-network rates, start now to prepare for tougher contract negotiations. See 2022 Surprise Billing Predictions: Lower In Network Fees & More Paperwork for why this has become much more important.
  • Being able to analyze and react to volume and reimbursement data and trends will become even more essential. This requires robust analytics technology and people skills. Finding and retaining these skills will be more difficult. Fortunately, professional billing partners can perform most of this essential work for you.
  • Contracting administrative functions, on a variable cost basis, will be even more valuable than in the past. Committing to the fixed and increasing costs of in-house administrative staff will be extremely risky in 2022.  

AdvantEdge offers practices and departments a way to reduce cost risk while assuring that proper reimbursement is obtained for each clinical encounter. With AdvantEdge, billing, coding and related costs are directly proportional to your practice’s patient volume. AdvantEdge also provides insights through practice analytics and skilled Client Managers that help identify and respond to trends. In addition, you gain a partner to help with compliance and security. Contact us today at 877-501-1611 or [email protected]

 

References

https://www.ama-assn.org/system/files/2020-prp-covid-impact-medicare-physician-spending.pdf 

https://ehrn.org/articles/early-2021-data-show-no-rebound-in-health-care-utilization 

https://www.lblgroup.com/healthcare-utilization-low-expectations-covid/ 

https://revcycleintelligence.com/news/healthcare-spending-utilization-remain-low-in-2021 

https://www.theatlantic.com/health/archive/2021/11/the-mass-exodus-of-americas-health-care-workers/620713/ 

https://www.beckershospitalreview.com/workforce/18-of-healthcare-workers-have-quit-jobs-during-pandemic-morning-consult.html 

https://www.fiercehealthcare.com/practices/ama-medicare-physician-fee-schedule-spending-dropped-nearly-14b-last-year-due-to-covid-19 

https://www.cbsnews.com/news/health-care-costs-rising-americans/ 

https://www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs

At the end of an eventful year, we look back at the stories that mattered most to you. Here are links – and a short summary of each blog in AdvantEdge’s Top 5 Medical Billing Posts of 2021. 

1. “Treating” Your Patients with CareOver the last decade, the payer mix has shifted dramatically towards patients, to the point that medical bills are nowa financial burden for a large number of patients. At the same time, the end goal is for providers to collect all money due for services rendered. In this post, we describe how AdvantEdge meets people where they are with compassion and empathy to help them meet their financial responsibilities with dignity and respect.  AdvantEdge accomplishes this through empathetic representatives, billing visibility, a variety of payment methods, and more. Catch up on how AdvantEdge’s philosophy translates into dollars for its clients.

2. 5 Coding Compliance Questions for Medical Billing Companies A medical billing company must have deep expertise and up-to-date knowledge about coding compliance to ensure that providers collect all money due for services rendered. You want to be sure your medical billing company has the resources to provide ongoing quality coding input and feedback; stays abreast of coding changes; quickly shares these changes with providers; offers customized support to clients introducing new services and procedures into their practices; and gives new clients assistance with prior coding concerns. AdvantEdge shines over the competition with proprietary software customized to meet the needs of every provider; leading-edge technology promoting accuracy and efficiency – and a skilled team of seasoned coders who are all certified with deep knowledge in your specialty(ies).

3. Is the Labor Shortage Hurting Your Billing Today? Tomorrow? – The ongoing labor shortage has lasted much longer than anyone anticipated –  and shows no signs of slowing down. Therefore, if you bill in-house, now is the time to consider the benefits of partnering with a leading medical billing company.  Recruiting delays, sick days, vacations, etc. led to collections delays in 2021 for many practices. At the same time, costs increased rapidly for in-house billing operations.With AdvantEdge, the fixed expenses of in-house billing are replaced with variable costs and you are supported every day by a large team of billing experts.

4. 5 Technology Questions for Medical Billing Companies – Whether you’re already partnering with a billing company or are looking to take on a new partnership, there are many details to consider to make sure you are truly optimizing billing outcomes. Examples include  workflow automation and catching discrepancies before they create issues. The ability to tailor workflows and technology to your unique circumstances is also essential. The accomplished team of AdvantEdge specialists uses powerful technology to ensure that your billing runs smoothly and efficiently – with the flexibility to make sure that your specific medical billing and coding needs are met. 

5. Fixing Holes in Your Physician Billing – Our billing experts take care of  “fixing holes” in your medical billing process, so you have more time to focus on clinical matters. Coding is just one of the complex factors that may cause gaps in your billing. Other factors include incomplete documentation; outdated contract rates;  outdated automation; and much more. Since many of these errors are preventable, AdvantEdge’s specialists are quick to detect  issues, conduct the necessary research, and make corrections on the front end to prevent issues from reoccurring. Along with understanding the importance of automation, our expert team also appreciates the value of good communication and collaboration with both clients and with each other to realize the best possible outcomes for providers.

 

We hope the information in AdvantEdge’s Top Five Medical Billing Posts of 2021 helps  your practice optimize and improve medical billing in 2022. To learn more, contact us at 877-501-1611, [email protected] or online. Also, visit our LinkedIn page.

Our 2022 Surprise Billing predictions are based on recent actions by insurers, medical societies and regulators.

2021 Surprise Billing Act Lessons

As everyone knows, major changes from the No Surprises Act (NSA) are scheduled for January 1. 

The Act is going into effect despite concerns among providers that the current regulations could incentivize payers to set artificially low payment rates, creating more narrow provider networks and reducing access to care. These issues were debated when the legislation was drafted and again during the CMS rule making in the summer and fall of 2021. See “’No Surprises Act’ Rule: Physicians Lose” for the details.

  • If enacted in its current state, the (No Surprises) rule will … “create an ad-hoc system of benchmarking which guarantees every patient in-network cost-sharing and in-network payment to physicians, while shutting physicians out of an independent dispute resolution process that accounts for their work and expertise in a meaningful way,” according to Dr. Daniel Guy, President of AAOS, the American Association of Orthopaedic Surgeons.

Most of the debate is about one specific aspect of the NSA: the “qualifying payment amount.” There is little debate about the other aspects of the legislation and the proposed regulations. See “No Surprises Impacts All Physicians in 2022” for the specific legal obligations placed on every provider. 

It is important to note that all physicians (and hospitals) have obligations, even those who are fully in-network.

2022 Surprise Billing Predictions

  1. In-Network Rate Reductions

It is clear that, if the No Surprises Act proceeds with the current CMS rules, physicians and hospitals must plan for much tougher contract negotiations, especially where current contract rates are favorable to the provider.In network rates threatened

The concerns raised by physicians and hospitals during the CMS rule making process have already become a reality. We predicted this last summer (see “All Anesthesia Reimbursement Driven Down by Surprise Billing Law?”) when we thought these impacts would affect providers over the next several years, rather than this accelerated pace.

  • In November, Blue Cross Blue Shield of North Carolina (BCBS) sent letters to anesthesiology and other practices in the state threatening contract termination unless the physicians immediately agree to lower payments by 10% to over 30%. This is according to the American Society of Anesthesiologists (ASA) and confirmed by BCBS. The No Surprises Act is cited numerous times in the letters as the reason for the reductions.
  • As a first step, BCBS is asking for a 15% reduction by December 15 or a “comparable counterproposal”. If that is not agreed to, BCBS plans to “proceed with identifying and executing on terminations of outlier contracts…”.

In a press release, ASA President Dr. Randall Clark said, 

  • “Instead of expanding in-network access for patients, BlueCross BlueShield of North Carolina has demonstrated what we explained to Congress and the rule-making agencies would happen: Insurance companies will use their overwhelming market power and the No Surprises Act’s flawed rules to push more physicians out of insurance networks and fatten their own bottom line.”
    • “The clear intent of the insurance company in taking this action is to improve its negotiating position against community physician practices in the dispute resolution process outlined in the recently released Interim Final Rule implementing the legislation.”

 

  1. Legal Challenges

Partly as a result of the BCBS letters, on December 9, the American Medical Association, the American Hospital Association and several hospitals and providers filed a suit to block part of the NSA implementation. 

  • The lawsuit says that, as currently configured, CMS regulations implementing the Act will discourage insurance companies from reaching in-network agreements. 
  • Instead, the suit says, insurers will force providers to use the arbitration process which, many providers say is biased in favor of insurers. (See “’No Surprises Act’ Rule: Physicians Lose” for the background). 

“Congress established important patient protections against unanticipated medical bills in the No Surprises Act, and physicians were a critical part of the legislative solution,” AMA President Gerald Harmon, MD, said in a statement. “But if regulators don’t follow the letter of the law, patient access to care could be jeopardized as ongoing health plan manipulation creates an unsustainable situation for physicians. Our legal challenge urges regulators to ensure there is a fair and meaningful process to resolve disputes between healthcare providers and insurance companies.”

The AMA, AHA lawsuit came after the Texas Medical Association filed a similar suit in November. 

On December 22, the American College of Radiology (ACR), along with the American Society of Anesthesiologists (ASA) and the American College of Emergency Physicians (ACEP) filed a federal lawsuit in Chicago saying that the CMS regulations are not consistent with the language of the legislation and will ultimately harm patients and access to care.

  • “The conscious decision by the White House to ignore the specific legislative language and intent of the No Surprises Act as the new law is implemented has empowered insurers to drastically cut reimbursement, narrow medical networks and restrict patient access to their chosen providers — including radiologists,” the ACR said in a statement.

Providers have support from some legislators, with 150 members of Congress reportedly pressuring CMS to modify the regulations to match their intent when the law was passed. At the same time, HHS Secretary Xavier Becerra has defended the final rule, urging providers to “tighten their belt.”

At this point in time (early January), there is no indication that the CMS regulations will get changed. It does seem possible that the regulations may be delayed due to the legal challenges.

 

Preparing for the No Surprises Act

Contracting

Given the 2022 Surprise Billing predictions described above, physicians need to update and enhance the rationale and data they use in contract negotiations. This will be especially important where current rates are well above local market averages. While those averages are currently hard to determine, as arbitration cases start in the spring, the “qualifying payment amount” (QPA) should become known (defined as the median in-network rate in the local market). Where you are out of network, your payments and your patient copays, etc. will be based on the QPA, which should also provide visibility.

“Paperwork”

As we outlined last month in “No Surprises Impacts All Physicians in 2022”, all providers need to take action starting on January 1.

  • All providers, even those fully in-network, must publish and publicize information about the No Surprises Act.
  • Almost all out-of-network billing reimbursement and patient billing will be required to change. 
  • Any referrals or scheduled procedures for self-pay or uninsured patients will require a good-faith cost estimate.
  • Billing must consider state as well as federal “No Surprises” legislation.

In December, CMS made several templates available to assist providers. They include forms for:

  • Notifying self-pay and uninsured patients of their right to receive a good faith estimate of expected charges
  • Generating a good faith estimate
  • Tracking the data elements that are required in the good faith estimate
  • Tracking required documents for the provider-patient dispute resolution process, which can be used when charges exceed the good faith estimate by at least $400

At the same time, HHS provided estimates of the time and cost overhead required to provide good faith estimates to uninsured and self-pay patients:  either 30 or 60 minutes (!) to generate each good-faith estimate, depending on whether items and services also are needed from a co-provider or co-facility. CMS has said it will exercise “enforcement discretion” during 2022 when the estimate leaves out co-provider charges.

 

References

https://www.healthcarefinancenews.com/news/american-society-anesthesiologists-accuses-bcbs-north-carolina-abusing-no-surprises-act 

https://revcycleintelligence.com/news/providers-accuse-nc-payer-of-abusing-no-surprises-act-cutting-rates 

https://www.healthcaredive.com/news/blue-cross-nc-surprise-billing-act-provider-rate-reductions/610501/ 

https://www.nytimes.com/2021/12/09/upshot/surprise-billing-act.html 

https://www.aha.org/legal/litigation 

https://www.usatoday.com/story/news/health/2021/12/11/no-surprises-act-has-doctors-pushing-delay-medical-billing-changes/6457833001/ 

https://www.beckersspine.com/orthopedic/item/53177-no-surprises-act-will-tip-disputes-in-insurers-favor-physicians-warn.html 

https://www.radiologybusiness.com/topics/economics/american-medical-association-lawsuit-surprise-billing 

https://www.hfma.org/topics/revenue-cycle/article/cms-makes-templates-available-to-help-with-some-administrative-a.html 

https://www.kff.org/health-reform/issue-brief/no-surprises-act-implementation-what-to-expect-in-2022/ 

https://www.auntminnie.com/index.aspx?sec=nws&sub=rad&pag=dis&ItemID=134640

https://www.jdsupra.com/legalnews/no-surprise-billing-rules-checklist-for-7120253/

We are pleased to present Part II in our series highlighting effective ways to fix holes in your physician billing. In Part I “Fix Holes in Your Physician Billing: Money Matters”, we described how to “plug” four holes that often lead to revenue loss. In Part II, we provide tips to plug 4 more holes that will help physicians collect all money due for services rendered.

1. The Sound of Silence: What happens when nothing comes back after a claim is filed? You don’t get a denial or an underpayment – or, for that matter, anything at all. You need a way to get an alert for each claim that winds up in a black hole – and a system to promptly forward that claim to the appropriate specialist who can quickly address the issue. Simply put, you need an automatic checking tool, to ensure that every claim is accounted for in the system – even those that are not responded to by the payer.

AdvantEdge’s technology flags claims that are overdue – and never responded to by the payer. These claims are treated as denials, and are quickly forwarded to the appropriate specialist who can address and resolve the status of MIA claims. 

2. Don’t Settle for Less: It’s important to flag underpayments because even small underpayments translate into significant losses over time. A $2 underpayment per claim can easily add up to considerable losses over a few months. That’s why it’s essential for a medical billing company to have the capacity to compare payments to contractual amounts and identify underpayments in a timely fashion. This is particularly important when a payer has the wrong amount in their system and the pattern can be highlighted for them to correct.

The AdvantEdge Virtual Manager system has the intelligence to recognize underpayments and flag them as if they were denials, so the matter is promptly addressed and resolved by the appropriate specialists. 

3. Why It’s Necessary: In cases of medical necessity denials, it’s essential to look at exactly why the claims were denied. Consider DEXA scans as an example. Radiologists may receive ongoing denials saying they are not meeting the definition for medical necessity for this service. What that often really means is that there was not a payable diagnosis code. In such cases, the billing company needs to educate physicians about medical necessity for that service so that they can provide appropriate documentation and/or help educate referring providers. 

When medical necessity denial trends are spotted, AdvantEdge promptly reaches out to providers to explain exactly what needs to be documented. This way, the root cause can be reviewed, addressed, and resolved.

4. New & Noteworthy: Changes to medical billing, including new coding requirements; coverage additions and deletions; and other regulatory changes are inevitable. That’s why it’s important for a medical billing company to keep up with current rules and regulations – and promptly inform their clients of these changes and how they can impact their bottom line. For example: The rules for colorectal cancer screenings are changing. Beginning in 2022, the removal of polyps during this procedure will change what used to be a screening test to a diagnostic test, meaning coinsurance will be required if polyps are removed. Promptly notifying providers of changes like this allows them to better communicate changes to their patients, as well as update their documentation templates.

AdvantEdge specialists constantly monitor industry changes, participate in industry and specialty associations, and immediately reach out to all providers impacted by changes in regulations and processes. Our goal is to give providers ample time to make all appropriate preparations for changes in the healthcare ecosystem.

Following these 4 tips of fixing holes in your physician billing, and the 4 tips featured in Part I of this series, puts providers in an optimal position to collect more money faster – without leaving money on the table. For more information on AdvantEdge, visit www.ahsrcm or contact us at 877-501-1611 or [email protected]. 

To make 2022 healthcare workforce predictions, we have to start with a careful look at the 2021 healthcare labor shortage. For a perfect storm of reasons – people wanting a fresh start in a new career, child care logistics, generous unemployment packages, early retirement, COVID fears, etc. – a majority of companies in 2021 felt pressures on both retaining and hiring employees. A recent Small Business Jobs Report reveals that almost 90% of business owners see hiring as “somewhat or very difficult.” And almost two-thirds have unfilled job openings. 

For healthcare, the pressure on clinical staff from wave after wave of Covid is obvious and currently shows few signs of abating. In addition, on the administrative side, practices have been impacted by the general labor shortage,  especially where practices have in-house billing operations.  

Before we dive into our 2022 healthcare workforce predictions, let’s look at the lessons from 2021. 

2021 Healthcare Workforce Lessons

  • In December, the Wall Street Journal quoted ZipRecruiter with estimates of 11 million job openings in the US compared with 6.9 million people unemployed but who want to work. 
    • “That’s the lowest ratio of unemployed people to job openings we’ve ever seen and that is contributing to unprecedented tightness in the labor market,” said Julia Pollak, chief economist for ZipRecruiter.
  • The “Great Resignation” has been underway since at least 2Q 2021 with nearly 3% of workers leaving their jobs every month! We have now seen a record number of “quits” for 8 months in a row.
    • Healthcare has a higher quit rate than most other industries.
  • According the Wall Street Journal, “American Workers Are Burned Out, and Bosses Are Struggling to Respond.”
    • “Employers say burnout, long an issue for American workers and exacerbated by the pandemic, is a prime cause. A September survey by the Conference Board found that more than three-quarters of 1,800 U.S. workers cited concerns such as stress and burnout as big challenges to well-being at work, up from 55% six months earlier. Half said workload-related pressure was harming their mental health.Healthcare worker burnout
  • A survey released by Morning Consult found that nearly 1 in 5 (18 percent) healthcare workers have quit their jobs since the start of the pandemic. The survey also revealed that of those healthcare professionals still working, 31 percent have considered moving to a new job.
  • The conclusion of a recent AMA survey says
    • “Approximately 1 in 3 physicians, APPs, and nurses surveyed intend to reduce work hours. One in 5 physicians and 2 in 5 nurses intend to leave their practice altogether. Reducing burnout and improving a sense of feeling valued may allow health care organizations to better maintain their workforces postpandemic.”
  • Some practices discovered that billing or coding staff shortages led to delays in payments and, in some cases, missed payments. 
    • Any breakdown in the coding and billing workflow can increase denials, resulting in delayed cash flows.

 

2022 Healthcare Workforce Predictions

No one expects the healthcare labor shortage to go away in 2022. 2022 Healthcare Workforce Predictions

  • A recent report by Moody’s Investors Services indicates workforce shortages are “poised to raise costs and whittle down performances of both nonprofit and for-profit hospitals well into 2022.” 
    • From the same report, “Many provider organizations are increasing their minimum wages for nonclinical staff to compete with other agencies, for instance, while at the same time rolling out retention and sign-on bonuses to maintain their nursing workforce.”
  • Ultimately, the verdict is split as to when there might be an end, or at least relief, to the worker shortage. Some optimistic economists the shortage will ease by summer 2022, while many others believe that both short and long term factors will cause the situation to extend into 2023, and beyond.
  • Whether the worker vs. job imbalance continues or begins to normalize, everyone expects that pay and benefit increases, flex hours and other actions that tailor jobs to worker needs will continue. The recent spikes in inflation will reinforce these trends.

Essential 2022 Healthcare Workforce Actions

Here are some of the ways to adjust to this new labor environment.

  • Plan and budget for increases in salaries/bonuses, incentives to attract talent, and improved benefits. But start by understanding your local labor market dynamics. 
    • For skilled positions, the large increase in remote work means that you may be competing with large employers located across the country.
    • For less skilled jobs, being flexible to accommodate child care, transportation and other concerns will increase your pool. 
  • Recognize that the shortage has accelerated a “ massive and possibly irreversible trend: that of giving workers a new sense of mobility they’ve never had before.” As a result, to hire and keep good employees, your practice needs to offer good jobs with opportunities for growth and promotion. This means investing more in supervision, training and leadership; i.e. this is a bigger job than just HR.
  • Consider more flexible work arrangements wherever possible. For example, part time and flex time, work from home, overtime, etc. These steps will help with both recruiting and retention, especially for younger and older workers.  Remember that your practice will seldom win a bidding war with a bigger employer. But you can win with flexibility, creativity and good jobs.
  • Consider contracting out administrative tasks that are difficult or expensive to staff internally. This can include accounting, payroll, coding, billing and more. The alternative is to commit more practice leadership time to administrative employee development.
    • Practices  with in-house billing departments will need to spend substantial energy (and money) to retain and hire competent medical billing professionals in 2022 and beyond. 

 

Large employers, like AdvantEdge, also see the same workforce dynamics. But companies like AdvantEdge are better equipped to retain and recruit skilled staff in several ways. AdvantEdge recruits from a national (in fact, global) labor pool. As a growing company, there are many opportunities for advancement. Professional training and development is in place across the company. Employees use and learn the latest technology. These factors mean that AdvantEdge clients are served by skilled coders and billers without the overhead of recruiting and retaining in-house staff. All at a variable cost that is generally less than the fixed costs of in-house billing. This means clients have more practice time to devote to clinical matters and growth. To learn more, contact us today at 877-501-1611 or [email protected]

 

Resources:

Wall Street Journal, December 8, 2021. “Jobs Gap Has Grown to Two Unemployed Workers Per Three Openings Since Summer.”

Wall Street Journal, December 21, 2021. “American Workers Are Burned Out, and Bosses Are Struggling to Respond.”

https://www.npr.org/sections/money/2021/10/19/1047032996/why-are-so-many-americans-quitting-their-jobs

https://www.healthecareers.com/medpage/article/healthcare-news/the-healthcare-staff-shortage-1-in-5-workers-has-quit

https://morningconsult.com/2021/10/04/health-care-workers-series-part-2-workforce/ 

https://www.fiercehealthcare.com/finance/moody-s-hospitals-staffing-agencies-shouldering-labor-shortage-while-insurers-are-largely

https://www.healthcarefinancenews.com/news/healthcare-lost-17500-jobs-september-amid-ongoing-labor-shortage

https://www.bls.gov/opub/ted/2021/payroll-employment-up-210000-in-november-2021.htm

https://www.businessinsider.com/jobs-report-october-democrats-midterms-economic-recovery-labor-shortage-healed-2021-11

https://www.businessinsider.com/why-labor-shortage-will-last-for-years-great-resignation-jpm-2021-12

https://fortune.com/2021/12/09/after-the-great-resignation-4-workplace-predictions-for-2022/ 

https://www.sciencedirect.com/science/article/pii/S2542454821001260

In this blog post, we describe how to fix holes in your physician billing. It is well known that physician billing is a complex process. Less well known are the many “holes” in the process where money can disappear. The best protection from these “holes” is sophisticated technology supported by trained medical billing experts. 

This two-part Money Matters series starts with four ways to fix holes in your physician billing with techniques and capabilities that plug physician billing holes and help providers collect all monies due for each service provided. 

  1.      First Time Around: The First Pass Clean Claims Rate informs us of the accuracy with which a medical treatment is converted into a billable event– and also has a direct impact on how fast or even if a provider will receive  all money(ies) due for services rendered to a specific patient. Having the capacity to find and fix simple errors like missing digits in an insurance ID or a social security number – or any other preventable mistakes – helps expedite the process and promotes the best possible financial outcomes. In other words, more money faster. 

At AdvantEdge, every claim goes through sophisticated Claims Editing software to power the submission of clean claims. The result is a first pass claim acceptance rate over 99%.

    1.     Heads Up: It’s crucial for a medical billing office to have a system in place to make sure all clinical services performed are captured and appropriately converted into a billable event. As an example, for anesthesia billing, the billing operation should have automated methods that review and compare the anesthesia OR schedule to the records captured in the billing system. This is the only way to ensure that if 100 cases are scheduled, these same 100 cases also get to coding, concurrency review, charge entry and then billed to the appropriate payer or responsible party.

Also, since billing information often comes from a hospital system, e.g. Epic or Cerner, glitches in HL-7 or other files can lead to missing information and result in delayed billing. Sophisticated monitoring and reconciliation processes are  required to identify and correct these errors quickly.  The flow of all of the demographic and clinical information that affects each claim needs to be monitored to ensure that nothing is left behind – and all money due is collected.

AdvantEdge’s Workflow Management Tools track all clinical activity and  time and date stamp claims as they move through the billing process or from one specialist to the next. Even cases that need to be moved out of the flow are tracked and monitored, so nothing is overlooked. 

  1.      Keep payer contracts current: Payer contracted rates can be complicated, making it difficult (or nearly impossible) to identify and track incorrect payments manually. And, of course, rates can change annually. To avoid payment errors, it’s essential for a medical billing company to upload current contract rates for all payers into their system on an ongoing basis, and be able to compare payments to those contracted rates to ensure that payers are complying. For example: If the reimbursement rate for a given service is increased by 1.5 percent, it’s important for the system to compare the current contracted rate to the amount paid to the provider. Even the smallest underpayments add up over time!

AdvantEdge’s Virtual Manager system loads the providers payer contracts to make sure payments match allowable amounts at the CPT code level. Where a pattern of underpayment is detected, these claims are re-billed to recoup the missing dollars and payers are notified in order to minimize the issue going forward.

  1.       Manage Denials:  Since denials come in many different “flavors” – and require immediate attention – it’s essential for each to be tracked and forwarded to the appropriate specialist, often based on reason code(s). While some denials may be coding related, other denials may involve incomplete documentation or other factors. It’s important to know the reason for the denial, so the issue can be properly addressed in minimal time and corrected at the root cause, so it doesn’t perpetuate.

AdvantEdge’s Denial Management processes automatically route denials to the appropriate specialist who conducts the necessary research and quickly resolves the issue. Where a denial pattern is detected, edits are added or corrections are made on the front end to rectify the problem moving forward. When denials are caused by inaccurate or incomplete documentation, this is a valuable opportunity to educate providers on how to improve their documentation – allowing for quicker and more accurate payments in the future.

These 4 ways to fix holes in your physician billing are important. But beyond powerful technology and skilled billing specialists, AdvantEdge realizes the importance of forging strong partnerships with each of our clients with a focus on communication and collaboration to keep our eyes on the goal – more money faster for healthcare providers. Stay tuned for Part II of this series designed to help physicians plug holes in the physician billing process and collect all monies due for each service provided. 

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AdvantEdge