Last week, CMS reported that 800 hospitals will be required to forfeit 1 percent of their reimbursement for missing the mark on reducing hospital-acquired conditions (HACs). The race to eliminate preventable patient harm has always been a top hospital goal, but now it’s one tied to their reimbursement through the Centers for Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program (HACRP). No matter how hard hospitals work to improve their performance, CMS will penalize the lowest performing quartile (25%) of hospitals annually.
A significant share of today’s hospital and doctor reimbursements now come from patients rather than commercial payers, yet many providers haven’t updated their collection practices. As charge amounts on medical bills continue to rise, healthcare providers are increasingly challenged to collect the high deductible amounts owed them. Patients are also more conscious of how much they spend on healthcare services as medical costs consume an increasingly large portion of their paychecks.
Declining reimbursements are one of the biggest challenges healthcare providers face today. Ask any physician or hospital and they will tell you about the daily struggle of getting paid for their services. However, many healthcare providers are leaving a significant amount of money on the table by under coding.
Most claim denials are due to the lack of verifying benefit information prior to services being provided. Insurance verification process is crucial for all hospital encounters, whether inpatient, outpatient or ambulatory care. It will ensure that the hospital or physician receives payment for services rendered and will help determine the patient’s share of the charges referred to as the patient’s responsibility.
The overall theme of this year’s HFMA Annual Conference is “Transforming the Business of Healthcare,” and it is right on target. No other industry is experiencing more evolution and transformational change than healthcare. It seems that the only thing we can count on is change — this is even more true for the business side of healthcare delivery.
In medical billing terminology, eligibility verification, pre-authorization, prior authorization and pre-certification are terms that may be used interchangeably to mean that for certain situations and procedures, providers have to contact insurers in advance and obtain a certification number in order to be reimbursed properly (or at all) for services. Insurance verification and insurance authorization services play a vital role in revenue cycle management. In fact, most claim denials happen when a patient is ineligible for services billed by the provider.
The RevCycle Intelligence e-newsletter reported recently that 80 percent of hospitals are vetting full revenue cycle management (RCM) outsourcing. The demand to outsource full RCM is up 86 percent from 2015 among hospitals and inpatient organizations. Approximately 80 percent of hospital leaders in a new Black Book survey of 709 C-suite executives, board members, and senior managers at hospitals and other inpatient organizations said they were vetting or considering outsourcing full RCM by 2019.
Many healthcare providers are under the impression they can assess their financial health by evaluating cash flow only. However, cash flow is just one factor in revenue cycle management (RCM). To maintain a healthy revenue stream, healthcare providers need to understand the other important metrics that should be calculated and reviewed when evaluating their revenue cycle.
Healthcare IT News reported recently that nearly three-quarters (73 percent) of health systems with more than 300 beds — and 81 percent of providers with fewer than 300 beds — are shifting their focus to IT outsourcing for development and complex infrastructure services. Their data was based on Black Book Research that surveyed 1,030 hospital CIOs and IT leaders and 243 CFOs and financial executives from 266 hospitals and the business managers from 1,400 outpatient, alternative care and physician practices for their insights on technology and outsourcing services options.
Here we go again! In my last blog I mentioned how companies like Amazon, Google, Apple, Uber, etc. will be driving innovations in healthcare delivery and costs over the next 10 years. Today, the Wall Street Journal (WSJ) reported that retail giant Walmart is in preliminary talks with health insurer Humana about developing a closer partnership, with one possibility being that Walmart might acquire Humana.