2024 Legislative Update: Implications for Healthcare RCM Leaders

Introduction

To get us started, I'd like to introduce our speakers for today.

Mark Janiszewski, chief solution officer of FinThrive, and Jonathan Wiik, vice president of health insights of FinThrive. So, Mark and Jonathan, I will hand it off to you.

Great. Thank you, Lily. I assume everyone can hear me okay and and see my screen. Please jump in the chat if you can't. Mark and I are honored to present to you today on on what's happening at mainly the federal level. We're not gonna get down into the state level, although the state mirrors many of these regs. But our backgrounds, I'm a political nerd.

I've been to the White House. I follow the federal regs pretty closely as does Mark. I guess we'd call us both medical nerds, or legislative nerds.

Very, very closely, I read the register.

When it comes out, I I need to get a life, my wife says.

Follow the updates, the when when when there's penalties and things happening. I'm not as close to the state level. So if there are state regulations that you're aware of that are impactful or relevant, please jump in and share those with Mark and I because I know we're both very, very interested. My background from the hospital space, Mark, has been in the engineering and product space on the software side of RCM for a for a very long time, considered an expert in the field as far as RCM and where we're at. So I'm gonna kick off the first, probably half of this deck by a lay of the land of what are some of the key regulations and things that are happening in revenue cycle.

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Key Regulations in Revenue Cycle

And then Mark will talk about how he's seen in the market from our customers and his own experience and some of the solutions that Finthrive has brought to market, folks are navigating compliance towards those regs. If that sounds like a deal. Mark, I don't have anything to add, but I'm gonna dive in.

Away we go. Alright. Let's talk about the market. So, you know, there's usually about five million or so in losses in annuals to denials, and one could argue that is a function of regulation or lack of in some regards.

Fifty percent of those could be be, prevented, I believe.

Only about a little less than a a a a little less than than two thirds of balances are collected on the patient's side. There's a high registration error rate just given the amount of data that has to be entered into the system to submit a bill.

More than two thirds of organizations struggle with compliance. I've got a administrative burden report that MGMA puts out every year. We're not gonna get too much into the detail of that today, but certainly happy to share it with the audience as we get through, today's presentation. If you'd like to see what things are most providers or even patient access for that matter given our audience are struggling with.

And then, finally, you know, there's about nine billion dollars in this revenue, and I I kinda call that the missed hoops, statistics that's out there. I think because of all the regs and all the different rules that insurance companies have, and they and they obviously don't pick up the phone and call the hospital back and say, hey. I think we shorted you last month. That burden of proof lives with the provider certainly does cause some some, issues.

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Administrative Burden and Compliance Struggles

There's just a lot of administrative folks. I'd be very interested to understand how many folks at your organizations have, you know, a a risk and regulatory, department and how many people are in there. You know, my hospital, we had, you know, three attorneys and and two analysts. And I'd say almost fifty percent of their time, we're really working on just keeping up with the regulations, be them from the OIG, from the state level, from the health department, from the joint commission, and and finally, just the federal regs that are out there.

Talk about the dials for a minute. I'm sure you guys are very familiar with this. Denial rates run anywhere between three and twelve percent. If you're above that twelve of initial denial rate, please reach out to Mark or I.

That would mean your your your significant outlier in the market, but most folks run-in the high single digits, sometimes ten percent or so. Over average overall is about six. What's frustrating is about eighty two percent of those on average, this is by payer, I love this report, are overturned.

And, and so that's just a waste. That that to me, that means that there's probably too many regulations or there may be not be enough on the payer side to manage, the payments that are coming through. But all the hoops that a hospital or clinic or physician's office have to run through to get something paid and then get told no and then argue for four to five months and get it paid again is really frustrating, and it's getting worse. You know, Medicare Advantage this last year has became the majority of Medicare enrollment. They have surpassed traditional Medicare, significant amount of folks there. MGMA, that burden report I mentioned to you has some statistics specifically targeted at MA plans.

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Medicare Advantage and Denials

You've heard from the American Hospital Association, the American Medical Association, several large systems including Mayo Clinic have and Geisinger have said they will no longer contract with Medicare Advantage because it's frankly too administratively burdensome to follow the rules that those plans on the private side have put together as they're managed there.

The why I'm bringing all of that background up on denials is that the government is getting involved in that. It doesn't feel like it right now, but the general accountability officer GAO is investigating that. They're looking at Medicaid in this report. There's some other ones out there that that will come through Medicare Advantage, and I imagine that will spill over to commercial.

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Federal and State Level Regulations

Understand that the commercial plans are regulated not necessarily at the federal level. They're managed at the divisional level typically at the state where their licensure is held. They have something called DORA, the division of regulatory agencies or division of insurance as you're aware, and those entities vary by state. There are federal laws out there like ERISA, Employment Retirement Income Security Act and others, Department of Labor.

There there's some acts out there surrounding the Affordable Care Act or Obamacare to talk about the minimal benefit requirements or MBEs, that are there on plans. But for the most part, the federal government kinda stays in its yard, and it covers, see, you know, all the government RAM plans, which roughly represent anywhere between fifty to sixty percent of the American population depending where you're looking. They did this study on Medicaid. I thought it was at least at my hospital when I was running my revenue cycle, Medicaid caused just as much, if not more than all of my commercial denials combined.

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Medicaid and Commercial Denials

They were the nasty ones, and I'm I'm told that they still are in most cases, especially managed Medicaid. They're right up there with the MA plans. And providers have been very vocal at the state and federal level saying, hey. We're just trying to save lives here, and we're trying to deliver care, trying to be in our community.

We're not we're only getting ten, fifteen cents on the dollar anyway, and you knuckleheads are driving us through the ringer trying to get us paid try and we're just trying to get paid, and and please investigate. So GAO did. And this is a recent report. They looked at the appeals and grievances.

They saw some of those overturn rates like I showed you even though those were specific to Medicare Medicare Advantage. And they they they're requiring states to report on appeal outcomes and the number of denials. And I think that's gonna be helpful. And as you go back to your organizations, I don't ask you guys to do too much homework when I'm talking to you, at the AM level because I know you're very busy in patient access.

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Impact of Reports on Managed Care

But do go back and and look at and ask your risk departments for these reports because they're out there. And, yeah, that could be used in your managed care department to understand how you could, one, lobby at the legislative level to reduce the sub administrative burden, and two, have more favorable outcomes with your contracts as they renew. I did wanna spend some time on the MA prior auth rule today.

It is not effective till twenty twenty six. There's a lot of folks going, oh, this rule's out there. It's you know, that's in about eighteen months or so. And it is gonna primarily impact the government plans, and then it'll roll out the QHPs and the HPE plans after that. And I do think we'll see some things following suit on the offside with commercially ran plans including those with Medicare Advantage.

We've outlined three key elements. They must have a specific denial reason. A lot of you might be saying, well, they give that today. They really don't.

If it if it says, you know, benefit not authorized or or, benefit exhausted or can't ID member or medical documentation not required or out of timely. I know I found that those codes were not, one, consistently defined at the parallel, and, two, consistently provided. So this is really gonna measure that closely. They also the timetable was looked at within three seventy two hours or three days.

It doesn't say three business days or this is calendar days for non urgent and and and, other days for this. Because as you know, hospitals never close. They're a hotel, a restaurant, and a physician's clinic all rolled up in one. Payers must publicly also report this, which I think is wonderful.

You get to see who the players are as they go. They establish h l seven, which is a fancy three letter term for basically the pipe that communicates between insurance systems and hospitals in terms of a certain language. And then fire, fast health care Internet resources really looks at those APIs or application programming interfaces. I don't wanna throw too much alphabet soup at you all, but basically, that they define how the data will be transitioned and shared between payers and providers.

And then stakeholders in the industry have actually applauded this. And I think this is gonna be a landmark legislation as far as leveling the playing field between authorizations, bad players, if you will, and others. And the link to the federal register is in this deck when you put it in presentation mode, it is live. I encourage you to go look at the comments. They're really, really interesting.

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Regulations and Healthcare System Users

Users, and purchases of our health care system, and they frankly are not satisfied. I'm gonna transition now into some of the regulations and where we're at, what's happening with with those. And they have the tools to compare organizations that can deliver. As you're doing things like transparency, machine readable file, no surprises act, which we'll talk about today, your hospitals or organizations reputation is frankly on the line.

You can save a life, deliver a baby, put an arm back on, cure cancer, help someone, you know, get their heart running the way that they need to do, whatever that is, wonderfully. And if you screw up the bill, they're gonna tell ten of their friends and never come back.

That same thing happens from the regulatory side, and I wanna talk about the regulations that are here today. So why is there so much pressure now with what's going on? Well, I think there's a lot of legislative pressure happening from the market, and it really is coming from consumers. No surprises, Zach.

It's probably the best example of that of, hey. I got this bill. It's like six times what it normally is, and I have no idea where it came from. And it was talked about probably for eighteen to thirty six months before it even hit the floor, and then it took another two or three years for congress to finally pass it even though the states already had some rules in place for but now there's a federal rule out there as well for no surprises act.

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Legislative Pressure and No Surprises Act

And there's a lot of employer pressure as well in terms of just, hey. We're paying the lion's share of our revenues to salary and benefits, and benefits are becoming very closely tied and being a large part, if not twenty to thirty percent of an employer spend. So they're saying, hey. We need to cut cost.

We need to look at utilization.

We need to have more rules out there that help kind of drive cost down and and make people go to the right places when they need care and not splash an ED as I used to say. High deductible health plans are out there as well. Those are more of a cost share. So if you're paying for it instead of a third party, you're absolutely gonna be more attuned to what is or is not covered.

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Market Competition and Regulatory Scrutiny

Market competition. I don't know about you, but in my neighborhood, and I know it it were marked from in Tampa, this is pretty prevalent. It's like Starbucks now. There are facilities freaking everywhere.

And, you know, it's great, I guess, if you're a consumer, but you can go to a village of of a village MD at a Walgreens. You can go to a a a Target or Walmart just closed, but you can go to a a, a a freestanding, ambulatory surgery center. You can go to a hospital, sometimes hospitals within a couple miles of each other. And as that kind of market, par level of services out there, you're gonna see more regulation, lots of regulation surrounding m and a activity and other things. Hospitals make money. And when they make a lot of money, a lot of eyebrows kinda go up and start looking at, well, are they making the right amount of money? They're not paying taxes if they're not for profit.

And should they be making that much money? Should we have regulations that look at how they're billing and how they're collecting from their patients? We'll talk about the CFPB proposed rules a little bit. I don't have a slide on it It was relatively new, but we'll talk through it here in a minute.

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Regulations Impacting Providers and Payers

Payers are making money too. Nobody loves insurance companies. I used to work for one, when I was getting my master's degrees. They they they have a role gang.

They they they absolutely need to be here. I do think they are and if there's pairs on the phone, I'd love to talk to you. I do think they're acting oddly in the last eighteen to thirty six months. They have the kind of playing hardball with a lot of providers and aren't, being partners, but more adversaries.

And I haven't seen it be this tumultuous in quite a while. And payers are making a lot of money. Now no one talks about the, you know, ninety billion dollars of claims that payers pay every year. They just talk about the two billion that got denied.

And so it's important to kind of frame it that way. But as they're making profits and as they're looking, the government's looking at that as well. And then, of course, you have legislation and media bringing us around. Care and payment are not equal.

This guy is so happy. His cardiologist saved his life, but then he gets the bill and or his son does. He's He's taking care of his care. And and that is the problem is there's this disconnect between care and payment, and that's where a lot of these regulations start to hit.

These are the big three.

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Penalties and Compliance with Regulations

Price transparency, surprise medical billing or the no surprises act, and then finally, payer price transparency.

I'm not gonna go into a super amount of detail here. You guys will have these slides as you look. But I do wanna look at the penalty line, the third one down there, and focus on that. Because we're gonna talk about hospitals have been sanctioned, and Jackson Memorial was just sanctioned, about two or three weeks ago. Eight hundred thousand dollar fine, gang. That's a lot of money. You know, you could convert that to FTEZ organization.

That's like, you know, laying off fifteen to twenty people in patient access. And that's a lot of money that the organization had to pay because they did not want to follow the rules. Now Mark and I talked to our customers quite often, and we've actually talked to some of our customers that have said they fundamentally do not agree with the price transparency bill, and they're complying it in the way that they feel they should. States like Texas and Florida and others have, and and Louisiana, and there's many others that have said, I've worked really hard for my negotiated rates.

Per those contracts, that's proprietary information. I don't have to share it. The government frankly doesn't care. They're gonna fine you, put you on a corrective action plan, and go.

But they're gonna say, well, I'm gonna wait for that to happen because in my mind, that makes more sense to me to keep my charges safe with my negotiating power and pay the fines than it is to give those up and have this race to the top and race to the bottom, which I'll talk about in a minute. No surprises act has a very small, violation rate there in the middle. I thought I'd share. It's only ten thousand dollars.

It's not a lot. But the indirect impact of surprise medical billing or no surprises act surrounds the IDR, independent dependent dispute resolution process, and something called QPA, which is the qualifying pay payment amount. And those two things are, I think, more at risk with no surprises act. And what that means in English is if you had an out of network bill, like my hospital, we were out of network with Kaiser, We got percent of charge.

So we had an ED visit that was, like, a hundred and sixty grand. We got a hundred and sixty grand from Kaiser. Well, now you don't get that.

Now now if if you're out of network and you didn't go through all the disclosures, they have to follow what the qualifying amount was, and that might have been fifty thousand dollars. So I lost ninety thousand dollars on my ED visit that was maybe covering or subsidizing other costs. That it's not necessarily a violation, but it's an indirect opportunity cost with surprise medical billing. And if you're out of compliance, I I think these fines are kinda funny in that way and that you're you're actually losing a lot more money by losing that amount.

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Payer Transparency Rule Enforcement

Finally, ERISA is is enforcing the payer transparency rule. That's relatively new. They followed the first bank that I that I mentioned there. Price transparent.

The payers have to post machine readable files and have all of their services there. They're just the reverse of what they're actually paying and where we're at.

Let's take each one of these and talk for a minute about how we're doing on these bills and or regulations of where we're at. Transparency is not new, gang.

It's health care is one of the few industries where you you you really don't have to know what the prices are to get services. I had a CFO tell me, out in Seattle at a very large hospital there. You probably could guess which one.

Say, you know what it is, Jonathan? It's legalized shoplifting. That's what health care is. You can go into the grocery store, take everything you want, and then someone else, the insurance company, may or may not pay you.

It's very frustrating. I'm not saying that everyone should pay right at the front, but if you think about any other industry, it's very interesting how health care is kind of guarded and dark and you can't see it. I one of my books, I talk about how it's a grocery store with the lights off. And there's a doctor putting all the stuff in your cart, and they're trying to and then you get to the register and the lights come on.

There's a bill for twelve thousand dollars. We're like, nope. Go ahead and take it. We'll bill your insurance company and let you know how it works out later.

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Timeline of Transparency Regulations

That's why transparency is here. This is the this is the timeline. I'm not gonna go into a super huge detail here, but know that this rule is fourteen years old. It's gone through many, many different iterations and enforcement levels.

But when PPACA came out, which was part of the patient protection affordability care act, part of the Obama administration, they talked about making public hospitals must make public their charges. And then it went through all these different iterations with IPPS rules. Trump even issued an executive order, and then CMS finally said, I don't think the market's paying attention. And so they put out rules and said, okay.

Let's let's put our money where our mouth is. We're gonna make hospitals have ChargeMasters online. And if we don't see it, we're gonna find you.

And and then they said, okay. Now we also wanna make sure that people can actually go in there and shop for those services, and they define three hundred shoppable services, or you can have an estimate estimator like Mark's gonna talk about. And and that's where we're at today.

Every rule that you see come out of Washington, I wanna say, follows this type of path. No surprises act is probably in the third or fourth Chevron here.

The rule comes out. It gets communicated. People follow it. And then they they they, monitor, then they enforce as they go forward.

But it went effective just three years ago. It's a relatively new rule as far as enforcement and fines. So it's a it's important to understand the market's still learning for the most part as they go, and the sources are here if you need to see them. This is a breakdown of the rules.

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The Big Three: MRF, Consumer Friendliness, and Negotiated Charge

Big three, I like to call them, the MRF or the machine readable file. The sections are there. The federal register, if you're like me, a nerd, you wanna go actually look at it, you can go down there and see what the rule says. But basically says you gotta have a file of every charge.

Not some charges, it says all charges. And where I see folks kinda get into trouble and where we at Finthrive see it, and Mark will talk about this as well, is that they've put everything out there but pharma, or they haven't done the bundle charges for their surgeries or their inpatient or those types of things, or we don't really know what our DME providers are gonna charge. I don't care. You gotta put them all in there and at least make a good faith effort to have it.

Consumer friendliness of standard charges for shoppable, I mentioned that. CMS defined to those. An estimator meets that requirement as well. Mike Mark will talk about that.

And then payer specific negotiated charge. That's the one that's got everybody up in arms. Most hospitals that I talked to that disagree with this rule disagree with the third element. They like one and two.

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Challenges with Payer Specific Negotiated Charge

It's where they start having to, open up their books and talk about what they've negotiated is when they get all fired up. You need to stay compliant with the new rules with the MRF. Those went into effect this month, sixteen days ago.

Mark will talk about what we've done at Finthrive to help with that. But basically, they had a dot CSV requirement that switched to a dot TXT requirement and a bunch of other things. And a lot of hospitals don't have an ability to go out, make a file, and make it public, and keep that maintained in an easy way. It takes an army of folks to do it.

And then if the if the format changed, it's even harder because all those reports have to get rescripted through the EHR. Lots of other changes have happened. You can go back to that link I showed you before if you wanna get to the specifics. But it's very, very important that your reimbursements are calculated correctly, and it's very, very important that you're on this.

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Importance of Compliance and Audit Preparedness

I've been in several webinars, HFMA annual, I I I attend HCCA things as well, which is a compliance association.

They are on this. CMS is absolutely going to investigate. CMS is absolutely going to audit, and they're gonna look at it. It's important that you're compliant as you move forward.

These are some things to think about as you're looking at the machine readable file rules that came in over the last few few few, few weeks.

What's the what's the purpose of the mandate? What should one evaluate? What security measures are in place to protect that data? What are some key components?

How should I accommodate unique changes in the contracts? And what is compliance gonna look like? So I'm not gonna read all these just in the interest of time, but go back and make sure you're there. If you don't, you're gonna end up on this list.

The link's right there at the bottom. And what I like to say about this list or I it may it breaks my heart. Is this is a forever list. If you look at the dates on there, twenty twenty one, three years ago, Alabama, I think it was, or Arkansas Arkansas.

Right, Mark? Arkansas was the first hospital to get a fine. Just last earlier in in in April in, in July July third, Jackson Memorial there at the bottom got an eight hundred and forty thousand dollar fine. The fines are the fines are the fines.

It's money.

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Impact of Fines and Sanctions for Non-Compliance

What's what's worse is is that this name is gonna live on the sanction report forever. CMS is is out there, and it's not that hard to not find. Hospitals that don't post their prices, you could Google stuff like that, and it'll come up. I'm gonna dive into no surprise billing here and keep us cooking along.

This is the timeline here as well. It is a relatively new law if you look at the if you contrast that with what was happening with transparency. So keep that in mind as we're walking through the regs and things here. But this was that second set.

No surprise billing or surprise billing that I talked about at the end. Huge impact. Massive confusion and interpretation with this one. And that's somewhat normal too.

Although, what I like to say about no surprises act is is Washington had a baby and they really don't know how to raise it to bear. They're really confused. It's hard. They They said, hey.

Let's have a baby, and they did. And it was the no surprises baby, but they do not know, like, how to change his diapers. They don't know how to keep it going. They don't know what school they're gonna roll it in, and they're getting asked lots of questions.

They've got a huge IDR backlog, all kinds of things that are going on. The rule just had changes even this this this year, early this year that came through. As I mentioned, the pairs and others have to have some of their things there. To simplify the no surprises act, there's really four big elements.

First and foremost, you cannot, even on a Sunday at three in the afternoon in the state of Alaska, bill balance bill for ED or air ambulance ever. And that if anything, I think if you do number one as an organization, you're good. And what I always tell people when they're listening to my Webex is about compliance is if you take anything away from Mark and I are saying today, please go back to your billing office and make sure that they've got a smart suspense or a claim or suppression logic built into the billing system that says, if insurance company not contracted and codes equal any kind of ED or air ambulance, stop bill.

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Four Key Elements of No Surprises Act

Because if you don't, you're gonna get in trouble, and it's very, very big deal. And that's a very simple rule to build. The other three rules in this really surround making the patient whole, if that makes sense. So if there's out of network benefits and they choose to have in network, because it was an emergency or or whatever, they're held the same.

There's something called reciprocity insurance, but they don't pay a higher co pay or higher deductible. You'll start to see plans getting phased out that say if you go out of network, it's a thousand dollars. You're in network, it's five hundred. For ED, that doesn't work.

You can do it on other things, but you have to have notice of consent and some of those things. And, again, those plans probably exist today. And what's that mean if you're already enrolled? Like I said, lots of confusion and lots of things that weren't thought about as you look at this.

Number three is that notice of consent provision. So, hey, Mark. You wanna go to MD Anderson because God forbid you get cancer. And you you you wanna go there because that's the place that you were told to go that has the best outcomes.

They have to tell you when you go there, hey. You're coming here for elective services. They're non ED. You got a sign here that says anything your insurance company's not paying that's out of network, you're responsible for or they can't bill you any different.

Now as consumers, we've all signed those forms. We've signed them at our physician's office. We've signed them at our hospital. We sign them for our spouses or our partners or whatever as they've gone in.

That's not necessarily what's new. What's new is is for a hospital to act upon or a clinic to act upon its out of network billing rights, that consent has to be on file. If it's not, then you go back to rule number two.

And then finally, GFEs, which I'm sure you've heard about by now. Good faith estimates. I would say the market is probably most compliant with this element, number four.

Everybody kinda gets this. The way the rule reads is that if you self pay or it's not covered by insurance, which is a really interesting principle, you have to, upon request, provide an estimate to the patient. K? Very, very, very interesting rule.

We'll talk about that in a minute, what we're talking about right now. I don't I have a whole deck on no surprises act. I'm happy to share it with you as we walk through later. But these are some things I'm seeing when I'm in the market that are surrounding, GFEs.

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Challenges and Gotchas with Good Faith Estimates

These are gotchas.

One, CMS and the links right there provided a form. If you're gonna be cavalier or maverick and make your own form, you better bet your bottom dollar that it looks very similar. But if you change the font, the order, or the contents, that's not gonna make an auditor happy. And I've been through Medicare audits and they don't like that. So there should be a really compelling reason why you're using a good faith estimate that does not almost exactly match the format that's coming from Medicare.

That's that not clear and understandable part. You provide it for everybody. That a lot of people like, well, I don't know what we're doing. We're just gonna give it to everybody.

That's not what the rule says, and that actually causes more confusion, and you can get in just as much trouble for that in medic with Medicare as well. You only have it two languages. It follows the same things with, the preferred language rules that you have with the joint commission. You've gotta run that report, find out your top, twenty percent of your patients if I remember right, and have it for all of those languages.

The rules are there as you can as you can read.

People only include primary and facility charges. It doesn't update. A good example of this is it's scheduled as an excisional surgery, and and it becomes an excisional excisional surgery when you come in. The amounts change.

The GMP has gotta change too. That one's gonna get a lot of folks as we get down into the weeds with this rule. Because when I was at the hospital, the number one reason why an estimate was wrong is because something changed in theater, in the OR, in imaging, or somewhere else. And what was scheduled was not what was built.

And that happens quite a bit because medicines and art not a science.

It was never sent. It expired. You had a price increase. I guarantee every one of your hospitals that's on the phone has an annual or maybe biannual or quarterly price increase or new charges. All that stuff's gotta be there.

This really perpetuates what Mark's gonna talk about in terms of having a partner with you to help talk through and navigate this because if they're there, that entity or third party is monitoring and maintaining these things and asking the questions at the time and prompting you to make sure that the charge master is mastering what's going on and your estimates are in line with the latest coding rules, so on and so forth as you move forward.

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Enforcement and Regulatory Updates

It's getting the enforcement's getting delayed, and Mark even asked about the slide when I was put together. He's like, really? Do we need to update this? They still haven't updated this in the register, which I find very, very interesting.

But as of twenty twenty two of of almost eighteen months ago here, they have extended enforcement into twenty three, and they haven't gone back and changed this q and a yet. And they haven't released a q and a to kind of address that. And like I said, they put the rule out there. Washington birthed it, but they haven't gone out and said we're this is how it's gonna work.

We don't know how convenient and co providers are gonna work. We don't know how the AEOB are gonna work. We're gonna talk about that here at the end if you like. All of that stuff is still kinda out there, but the enforcement's kinda stuck.

And then HHS is deferring enforcement.

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Proposed Rules and Implications for Medical Bills

CFPV also said watch it. And they just came out with proposed rules about thirty days ago. These are very, very important for you to understand in that there's a rule out there, gang, that says medical bills will never be reported on credit. That's basically what the rule says.

There was a five hundred dollar cap. That rule just came out. And I didn't put it in here because it's still getting looked at as proposed. That's something that you should be talking to with your risk department and the collection agencies as you walk forward.

And it's directly related to this no surprises act, and it's also just related to medical bad debt, as you're as you're looking at things coming through. I'm gonna turn it over to Mark now, and he's gonna talk about the RCM platform approach to regulatory compliance. And, Mark, I'll turn it over to you, sir.

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RCM Platform Approach to Regulatory Compliance

Thank you, Jonathan, and always great, updates, information, and insight, on regulatory changes that you provided. So I'm sure everyone appreciates that.

Good afternoon or morning, depending where you are. I was gonna talk a little bit about how technology can be leveraged to help ensure that you and your organization remain compliant and above board on the right side of all of these regulations as they shift and change.

So something that we are seeing in the market is a desire to consolidate, RCM vendors to achieve a few goals. Certainly, drive better outcomes and greater, KPI results by having one vendor or fewer vendors that can work in an integrated way. Drive workforce efficiency. The vendor consolidation itself leads to fewer contracts, fewer renewals, fewer relationships to keep up, and fewer updates to keep up with. But as well, by having a single platform or fewer platforms, you can have a single source of data and ensure you have greater level of compliance throughout your revenue cycle, front, middle, and back.

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Benefits of RCM Platform Vendor

So this is a view of what a an RCM platform vendor can provide to you across, like I I said, the the spectrum or continuum of the revenue cycle.

It can help both with your hospital and your physician based, compliance efforts. And it also make sure that you are, identifying possible compliance issues as early in the process as possible and provide a feedback loop so that things you hear or learn about later in the cycle, you can implement further upstream and prevent it from occurring in the future. So I'll take you through a few of the the key components of this that are particularly important when it comes to compliance and regulatory adherence.

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Importance of Payment Estimates

Alright. First, let's talk about payment estimates. We we heard about the, both the no surprises act, and, etcetera earlier.

A lot of difficulty necessarily in being able to generate these estimates. If you don't have an automated system or technology to assist you, try to go manually look it up, keep up with a a little Excel printout that you post up on your corkboard beside the monitor, or go on websites and look things up one by one, very time consuming, prone to error and variability, not something you can rely on. And so being able to comply with these regs by having a more automated system that provides the estimates both to your staff as well as can provide an estimate to a consumer, which is what patients are becoming, for them to look it up for themselves, keep you regulatory compliant, but also create a better patient experience. And that's a big, I think, growing buzzword in health care is that patient experience and a positive patient experience as they become consumers and we become, people that need to be more consumer oriented as we go forward.

And so systems are able to provide, those good faith estimates. They're able to provide an estimate both in written form and on the phone or via website, and serve that desire and need of the patient to understand what their costs are gonna be before their care, is scheduled and, and occurs.

Some of the benefits of an estimator tool, you're gonna get greater patient satisfaction, less likelihood that you're gonna have double charge them or overcharge them or that you're gonna have to come back and try to collect from them afterwards when they thought they had paid what they owed. We as we saw with the the write offs from patient liability, the earlier you can collect accurately, the greater percentage of those patient, revenues you'll be able to rely upon as you go forward and not have to write things off as bad debt. And it's obviously more efficient to collect upfront. Sometimes without any human intervention whatsoever if the patient's preregistering themselves and doing their own payment based on the estimate provided all online or all on their phone, is the most efficient way to collect, and you get the cash in the bank earlier as well.

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Generating Machine Readable Files

The other thing that these solutions can provide, and it can happen whether it's a patient estimation system in the front or it's a contract management underpayment type system in the back end, is because they have all of your contracts, you know, codified, if you will, and can calculate the expected payment for any procedure, any plan, they can generate the MRF or machine readable file for you. And, as we covered July first, a new more expanded and a little bit more difficult to compile and put together, MRF file format went into effect. It'll probably start to get enforced around September first or so.

So a couple of months grace to get people some time to get these things up and running. But what we found and heard from our customers is whereas many of them, let's say, about a third, were able to create their MRF themselves or with a consultant or maybe through their EHR, most of them are saying they cannot do that. They cannot comply with the new expanded MRF format all by themselves via consultants or their EHR either. And they're turn turning to estimation or contract management systems to be able to generate those files.

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Success with MRF Generation

And so we have both of our our solutions that generate an MRF, our estimation, as well as our contract management system ready to go. I think many other vendors do as well.

And we're seeing great, success in terms of very quiet customers are pressing the button, answering a few questions, and then generating their files and uploading them, and doing their own quality checks and not finding any issues with them to the point where we're just calculating this. We have we have priced over a billion separate, plan, and procedure combinations to generate these files collectively across our customer base. So that's a hard thing for a consulting firm to try to emulate in an Excel spreadsheet as we go forward.

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Importance of Charge Master Compliance

Also, an area of compliance and one that perhaps sort of works and toils in obscurity sometimes is your CDM department and your charge master.

There's a big element with charge masters of making sure they're compliant, that the charges map to a current code and not an obsolete code, that you do have, codes in place where they should be there for all of your charge master items. And today's charge master can be quite a big and complex, beast, if you will, off often in the hundreds of thousands of items. Making sure that they all are compliant and combing through them to find out where there's compliance issues, identify that, and suggest appropriate changes to get back into compliance is really something that without automation, your organization is at risk, by not having.

And so, we've had great success with our customers. There's, other vendors in the market that do as well by helping those CDM departments, but often aren't very large in terms of staffing. One, two, or three people, keep up with all of the not only requested changes and adds to the to the charge items, but also making sure all of the charge items continue to stay compliant as they go forward.

So it helps prevent, both revenue loss and eroding margins, because you may have charges missing or the charges don't have a a price for them. You may can also use these solutions to identify where you're upside down between cost and price or volume charged versus volume purchased, and then you've got leakage going on in your system. And then they definitely have a very large compliance element to them, making sure you've got, each charge being compliant in its own right so that the charge master overall is compliant, and you're producing compliant charges that go into the claims and off to the payers.

We believe that, ChargeMaster system should be cloud based and cover both hospital and professional charge items. Also should cover supply pharmacy as well as, procedure codes so that, all of your chargemaster can be as automated and compliant as possible.

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CDM Automation and Compliance

Also, if you are a multifacetility in terms of your organization, you can make sure that you're consistent across facilities by having an enterprise wide view, and making sure there's consistency between your facilities so that your charges and if you are billing a cost of charge are consistent from one facility to another, particularly if you're gonna have a mobile patient population that may go to different locations to get different procedures.

And then, ideally, any updates you make in your CDM automation system should flow automatically back into your EHR, which really is the source of truth where that Chargemaster lives.

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Ensuring Compliance and Accuracy

So what does it help you do?

Ensure compliance and accuracy, drive system wide standardization, and then ensure you have defensible pricing.

So look for a system that has DOJ approved proprietary pricing benchmarks that cover at least ninety five percent of your CDM so that you can ensure that your pricing is defensible, as well as you understand where you are with your, as well as you understand where you are with your in your region and with your competition from benchmarking perspective to the greatest extent possible.

And then finally, maybe or second to last, one other item in the compliance area is a charge capture or we would call revenue capture, solution that looks at your charges as they are moving over into the billing phase and ensures that there are no, missing charges, there are no overcharges, and that all of your charges are compliant with the right mapping to codes, and fit within the overall context of the procedures that were performed for that, encounter and that patient experience.

So, a lot of that has to do with building up a rule set and making sure you understand when there are areas that often are missed or should not go together. I'm not a clinical person, but I know couple of, you know, examples around missing charges being if you're gonna do IV infusion. You gotta have have the procedure charge for the IV, but you also wanna have the pharmacy charge for the actual content of that IV. And you certainly don't wanna have, you know, any claims going out for, an OB or, labor and delivery experience for a patient who's listed as being of a male. At least typically, you don't wanna do that. So, this can help prevent those kind of issues. You wanna do this in a pre bill format to the greatest extent possible, which means you have to be right on it and the system has to be responsive because you don't wanna hold those bills any longer than you have to to get them out the door and keep your cash flow humming.

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Reducing Denials and Improving Clean Claim Rate

So, ultimately, what this does, it helps reduce denials, which delays payment and causes a lot of rework, improves your clean claim rate, and avoids you having to issue credits, to the payer if they should pay. And then they do an investigation or audit later, and then they determine that they wanna do a clawback.

All of it can work with your platform so that it can help provide and estimate the the charges at a net level in conjunction with a contract management solution. And it should also integrate with your CDM so that you're using the most recent charge master when you're comparing the charges coming in to see if there are any missing, overly stated or compliance issues as well.

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Increasing Workforce Efficiency with Automation

All of this can help, increase workforce efficiency, allowing your workforce to work faster and smarter by helping prioritize what they work, making sure the work lists are organized in a way that you're working with either the highest charge elements or the most, significant compliance issues first and foremost. Ideally, by automating, you're also able to keep up and get all of the work done. You know, here at Finthrive and I'm sure elsewhere, we do RPA, robotic process automation bots.

It's interesting to find that, we can automate processes that were estimated to take two or three FTEs. When we look at the the volume of what's being processed, it's actually six or seven FTEs worth because it turns out not all the work was getting done, with those two or three FTEs. And so any automation you can do often allows you to get to the bottom of your work queues, which you may or may not be able to do or be doing right now in the in the current state.

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Overall Solutions for Compliance

So finally, taking a look across, there's a number of solutions that can help you stay more compliant, and, on the right side of the regulators, and whether it's in patient access with estimations and good faith estimates, as well as the machine readable file, whether it's in the middle space with CDM, revenue integrity, revenue capture, making sure you're compliant and that you're, also compliant in the charges being applied to the claim. And then in the area of contract management, there's an element of machine readable file as well that can help you stay compliant with all of your pricing activities and put you in a better position when you're negotiating with your payers.

Alright. Thank you, Mark. I think that, brings us to the end here. I've been monitoring the chat and q and a while Mark was talking.

There was a question in there surrounding, GFEs and and creating your own form and making it electronic. The form that CMS provides is a interactive PDF, if I recall, and then, like, Finthrive, for example, has emulated that within our solution. So that my point in that slide is that you certainly can, you can look at that requirement, but you don't want to deviate from what, that requirement is or where the formatting is there because CMS, you know, ran all that stuff through different regulations. They they actually have things on font size and others.

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Creating Electronic Forms for Compliance

So if you are going to create your own form, just make sure that you kinda hold it up and give it the the the gut test or the smoke test, I like to call it, to make sure the sniff test that it matches. That was one question I saw. I didn't see any others in there, Lily, but if there are any, we certainly could open it up for phone, and Mark and I can help address that, or I could talk through some other things as well.

Yeah. I think we have some time. So if anybody wants to put any questions in the chat, we do have about ten minutes or so left, so now would be the time.

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Discussion on Compliance and Transparency

While we're waiting for the questions to come through too, I think some of the things I've seen in the market, transparency, I think folks are are mostly compliant now. Mark and I watch pretty closely what's happening, and I'd say somewhere around seventy percent. It might be as high as eighty now, especially since these spines are starting to come out. So the majority, especially kind of the larger hospitals are compliant or if they're not and being investigated once they get that corrective action plan, that they're working. And CMS sent out about four hundred letters at the beginning of the year, and about a third of those or maybe about a quarter of them, a hundred or so, had, you know, findings. And and you could see that out of those hundred, only about fourteen actually ended up getting fined and looked at. And and honestly, it's it's pretty hard to get a fine from CMS.

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Enforcement and Compliance Challenges

You're you're you're ignoring what they've given you, and and you know the rule. They've told you what to change, and you've probably made a business decision to not change it. And that might be some the result of some constraint on your end. As Mark talked about, you may not have the resources to update your charge master or your estimates in such a way that CMS is requiring.

I think you're gonna see more of that on the no surprises act provisions specifically in GFE audits or balance billing audits. And I think the difference in transparency and no surprises act is that the note the transparency enforcement's gonna come from findings that CMS finds. The no surprises act enforcement is gonna come from patient complaints or consumer complaints. It's gonna be people saying, hey. I got a bill or no one consented me or I had no idea. And those are gonna carry a lot more weight, I think, and you'll see more things happen on that no surprises act side than the others.

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Medicare Advantage and Contracting with Insurance Companies

Other questions in there yet? I'm looking to see if any of can yep. There are. Okay.

Here we go. You mentioned several hospitals are no longer accepting Medicare Advantage. Do you see this happening more in the future? I know I am seeing more advantage coverage than Medicare.

Yeah. So, you know, hospitals and I see a question on GFE too. So let's talk about Medicare Advantage for a minute. So, you know, I'm seeing organizations whenever they contract with insurance company.

Right? Let's kinda go back and pull a stick and look ten thousand feet at that. When a when a when a hospital or a health system contracts with an insurance company, it's a trade.

Insurance company, I'm gonna trade you referring people to me so that I can keep my volumes up and maybe I'll get more, and I'll give you and your members a discount off my charges. So it's kind of like Costco or or Sam's Club, if you will. That's a lot of what insurance contracting is. As weird as that sounds, people pay a premium into their insurance company and that gets them access to the network of discounted charges.

The the only difference is is that the insurance company is also assuming a a fairly large amount of liability. Now it's up to the provider or not to contract. What's happening with Medicare Advantage, to your question, Marcela, is is it's not worth it.

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Challenges with Medicare Advantage

The payment is not that incrementally better than Medicare traditional anyway. And secondarily, the administrative burden in terms of the additional rules, co payments and collections and and deductibles and coinsurance, because that often changes too on the benefit plan level is not worth it. So organizations like Mayo and I believe Geisinger, and I've got the list if you want to see it, have decided, you know what? We're not playing ball.

The government knows this and they want Medicare. They came up with it. They want Medicare advantage to expand. So that's why that rule that I shared is coming out there so that they could remove that administrative burden to make the playing field more level between traditional Medicare and Medicare Advantage.

But I don't think you're gonna see as many hospitals start to term their contract with Medicare Advantage as we have in the last few years. But I do think you'll see more, but just probably not as a bigger rate, if if that answers your question. And and, Mark, I don't know if you have anything to add, but that's my Yeah.

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Insurance Company Practices

I was gonna add a couple things. In terms of burden, because of the unique nature of Medicare Advantage where you have insurance companies managing it on behalf of the federal government, they have they have identified that the the more they can prove that the the population or the cohort that they're responsible for that are signed up for their Medicare Advantage have a higher level of acuity or case mix mix index, the more revenue they earn. And so they are doing things like auto denying every claim, asking for a copy of the chart, Not because they wanna see the chart in order to pay the claim, because they want a copy of the chart to go prove higher level of acuity or CMI.

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Provider Response to Insurance Practices

The moment they get the chart, then they pay. And so I think what you've got is a a number of providers who are saying, this is ridiculous. Let's come to a better arrangement. I'll just give you access to my EHR.

You can go look up any chart you want.

And in exchange for that, we you're gonna pay right away. You're not gonna go through this phony denial process. That may be a bit of a an exaggerated view, but it's certainly a view I've heard from several customers.

I think this is putting their foot down, try and create a sea change of how this operates.

So it'll be not a long term event, and there may be a few more that do the same thing. But I think they're what they're trying to do is get the attention of the administrators so that, they can make some permanent changes that work for both.

Agreed.

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Questions on GFE and No Surprises Act

There's a question on GFE applying to in network deductibles coinsurance. You know, that that's a great question. HFMA has gotten that question as well. And it what's the line between people that have insurance and people that don't or this noncovered?

And that's where it's gonna come into place from whoever answered the question is. GFEs are primarily they're they're good faith estimates at least today are focused on self, I'm sorry, on self pay or uninsured populations. Now self pay is the part where the waters get a little bit muddy because if the insurance company has a plan benefit exclusion or something's not covered or they denied something or someone's waived out of their insurance through HIPAA HITECH, then the GFE applies. And the government hasn't had a really good take or FAQ on how that works.

 

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Application of GFE and No Surprises Act

I don't know if in the appendix of this slide deck, I put it. I don't think I did, but in my no surprises act deck, which you're welcome to email me. My email's here, two i's and a k. I'll send it to you.

It's got a question related to that, and I'm I'm gonna paraphrase it. But, basically, it says no. It says it doesn't apply to in network deductibles and coinsurance because the net in network deductibles insurance are known to the patient. The hospital knows that as does the payer.

All three entities will bill accordingly, and there isn't any balance billing happening. The the purpose of no surprises act is to do exactly that, remove surprises. So when you're self pay, everything's a surprise because you don't have coverage. And if something's not covered, then it's a surprise as well.

And so the balance billing occurs there. That's my interpretation of it, and, certainly, I'll I'll point you to that CMS resource as well.

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HIPAA and Access to EHR

Let's see. Robin's got a question. Would giving access to the patient's EHR be HIPAA since they can see everything, not just what medically necessary for the auth request. Would giving the patient's EHR be HIPAA case?

So I think I think I thought the comment I made about some some providers saying, you create a direct interface.

You can go into our EHR and look up the files that you need.

I'm not a HIPAA lawyer, and I aspire never to be a HIPAA lawyer, because it can get quite complicated. But I would say with respect to, you know, TPA treatment, payment, and operations, I think this fall could fall within the payment end of it. Certainly, a payer wouldn't be able to go in and look up any medical record for any of their members or nonmembers.

They would need to do it in conjunction with a claim or an encounter that was active. But by automating that so they can go do it, they don't need to necessarily ask for, the chart after the claim's received. They could go do it themselves and then allow the claim to be processed. So somewhere in that realm, there are ways to work this out where there's less back and forth and there's less circular cycling and recycling of the same work that is not is an administrative burden for both the provider and the payer.

Right. HIPAA's got something called TPO to treatment payment operations, and it falls under that payment category. So if there's a payment associated with it, which typically the insurance company is there, those disclosures or permissions for said disclosures don't have to happen as often as as Mark articulated.

But, yeah, I don't think so. Again, I I didn't stay at a Holiday Inn last night either. I'm not an attorney. That's the way I see it.

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Closing Remarks

Yeah. I think the q and a is all clear, so I'll close this out. But in closing, we'd like to give another thank you to our sponsor FinThrive, to our presenters for sharing their time and expertise with us, and to our attendees for your participation today.