Seven healthcare regulatory changes that can impact your revenue cycle management
Like many areas of healthcare, revenue cycle management (RCM) is ripe with innovation and disruption in response to new healthcare regulations. In this article, we’ll address seven regulatory-related changes and explain how you can prepare for the future of RCM.
1. Telehealth expansion. Payers continue to embrace telehealth even after the conclusion of the COVID-19 public health emergency. What does this mean for RCM innovation? Important changes to the front end of the revenue cycle, namely online registration, online consent, and patient self-scheduling. Secure payment portals are also an important component of telehealth. If you haven’t already laid the technological foundation for an increasing demand for telehealth services, there’s no time like the present to start. Partner with a vendor that recognizes telehealth isn’t going away—it’s only going to move more into the forefront of today’s healthcare landscape with new healthcare regulations paving the way.
2. Increased focus on Medicare Advantage. Did you know that federal spending for Medicare Advantage enrollees was $321 higher per person in 2019 compared to if enrollees had been covered by traditional Medicare? This additional federal spending per Medicare Advantage enrollee resulted in about $7 billion in extra expenditures. CMS’ announcement of its intention to strengthen the Medicare Advantage program through more robust audits and recoupments has a direct impact on RCM. More specifically, revenue cycle teams need a laser focus on accurate risk adjustment coding. Without ongoing education, medical coding errors can ultimately put your revenue at risk—particularly as more payers move toward capitated payment models and population health management.
3. Price transparency initiatives. Whether it’s the No Surprises Act, the hospital price transparency rule, the health plan price transparency rule, or the Inflation Reduction Act to lower out-of-pocket prescription drug costs, the message of these healthcare regulations is clear: We’ve moved into an era of patient engagement and empowerment. What does this shift mean for RCM innovation? Medical billing staff must be armed with technology that provides accurate up-front cost estimates and be able to explain the cost of care to healthcare consumers. This again requires ongoing education for front- and back-end revenue cycle staff who may increasingly become your healthcare organization’s competitive advantage.
4. Behavioral healthcare expansion. Behavioral healthcare continues to remain a top priority as evidenced by recent federal efforts to expand access and make it easier for millions of Americans to select a health plan in 2024. The impact on RCM is this: Medical billing staff must be aware of behavioral health coding and billing pitfalls and take proactive steps to avoid them. Two of these pitfalls include frequency limitations and unspecified diagnosis codes (especially for alcohol use, abuse, and dependence; drug use, dependence, and abuse; and depression). In addition, patient collections can be a sensitive topic that requires nuanced communication and empathy. Ongoing training and internal audits will be paramount moving forward.
5. Increased resources to address health equity. Given CMS’ recent announcement it will make health equity adjustments in the Hospital Value-Based Purchased Program and encourage primary care physicians to contract with community based organizations under a new Making Care Primary model, it’s more important than ever before for revenue cycle teams to capture social determinants of health (SDOH) codes on all medical claims. Provide education on how to capture these codes and start talking about how to leverage SDOH data to improve patient care and outcomes.
6. Medicaid redetermination. Experts predict millions of Americans could lose their Medicaid coverage with the end of the continuous enrollment provision that ended on March 31, 2023. As the Medicaid redetermination process continues to rollout nationwide, revenue cycle teams plan an important role in verifying Medicaid coverage through streamlined, real-time eligibility checks and potentially pointing patients toward the state’s health insurance exchange or determining whether they’re eligible for charitable discounts.
7. Administrative simplification. Given CMS’ push for administrative simplification and standards for healthcare attachment transactions, now is the time to explore the increasing role of RCM automation. How can you promote RCM innovation to improve productivity and efficiency? Examples to consider: Automated patient communication, eligibility, and claim tracking.
Conclusion
New and emerging healthcare regulations continue to inspire new and improved RCM workflows and procedures. Leveraging these changes is paramount. Learn how edgeMED can help and be sure to check the Healthy Snacks blog for more expert insights, best practices and industry trends.
