By: Roberta Peters, MS, RHIA
Vice President, Solutions Executive, eValuator™
Streamline Health

Just when you start to feel moderately confident in your organization’s approach to achieving revenue integrity, changes come along that complicate your strategy. Regulatory and compliance changes add uncertainty to previously established processes, requiring organizations to scramble for a solution, either via training, process updates or other manual means. Nearly every week, there are new regulations to comb through, new rules to apply, and new compliance traps to avoid—all while dealing with the existing operational challenges from the pandemic.

With most regulatory changes, it’s not enough to simply understand the impact it has on individual cases. You also have to develop and operationalize a solution that works within your existing processes and staff. Consider the following four regulatory changes and corresponding action items that should be on every CFO’s radar. Then think about how much easier it would be to manage these—and other changing variables— with the help of pre-bill technology.

1. A new definition of medical necessity.

The Medicare Coverage of Innovative Technology (MCIT) pathway proposes a revised definition for determining whether an item or service is ‘reasonable and necessary’ for Medicare coverage purposes. In particular, CMS proposes that medically necessary items or services must be:

Staying Ahead of Healthcare Regulatory Changes During COVID-19 and Beyond

“Automation such as a rules-based analysis of coding would codify these new requirements and easily identify cases with potential compliance issues. And with regards to medical necessity confirmation, the most effective approach would include analysis prior to billing.”

  • Safe and effective,
  • Not experimental or investigational, and
  • Appropriate, including the duration and frequency that is considered appropriate for the item or service in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member;
    • Furnished in a setting appropriate to the patient’s medical needs and condition;
    • Ordered and furnished by qualified personnel;
    • One that meets, but does not exceed, the patient’s medical need; and
    • At least as beneficial as an existing and available medically-appropriate alternative

Interestingly, CMS also proposes that an item or service would be appropriate for Medicare patients based on commercial health insurers’ coverage policies—unless evidence supports that differences between Medicare beneficiaries and commercially insured individuals are clinically relevant.

Action item: When it comes to medical necessity, these proposed changes don’t necessarily un-muddy the waters. However, if CMS finalizes them, organizations will need to determine the impact and train staff accordingly. Automation such as a rules-based analysis of coding would codify these new requirements and easily identify cases with potential compliance issues. And with regards to medical necessity confirmation, the most effective approach would include analysis prior to billing.

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2. Resumption of RAC audits nationwide.

Another recent regulatory change is the resumption of RAC audits that had been previously paused since the beginning of the COVID-19 public health emergency. Even the American Hospital Association’s desperate plea couldn’t stop CMS from re-starting its efforts in what has become a target-rich environment. What could be at the top of the list in terms of compliance vulnerabilities? Consider the following:

  • COVID-19 cases for which organizations received a 20% higher reimbursement. The 20% payment increase will be low-hanging fruit for RAC auditors. This payment increase, which went into effect for COVID-19-related admissions on or after January 27, 2020, is a code-based payment adjustment. Prior to April 1, the increase was driven by ICD-10-CM code B97.29. However, as of April 1, that code changed to ICD-10-CM code U07.1.As of September 1, organizations that receive the 20% payment increase must have a positive COVID-19 lab test documented in the medical record. This test can be performed either during or within 14 days prior to the hospital admission. It can also be performed outside of the organization (e.g., at a pharmacy chain or independent urgent care clinic).Don’t have a positive lab test in the record prior to final claim submission? You probably want to  decline the 20% payment increase. To do so, enter a Billing Note NTE02 (“No Pos Test”) on the electronic claim 837I or a remark “No Pos Test” on a paper claim.
  • Telehealth—particularly billing telehealth when no services were rendered, upcoding due to insufficient documentation, ignoring state licensure requirements, and billing for telehealth visits that require audio and visual when a provider only uses audio.
  • Remote patient monitoring services—particularly a lack of medical necessity and incorrect reporting for duration of services.

These new issues are in addition to the evergreen ones—lack of clinical evidence to support CCs, MCCs, and HCCs; incorrect principal diagnosis; and more. It’s a laundry list that keeps growing longer by the day.

Action item: Each of the above issues reflects a complex new requirement that coding staff have to take into account. Once again, technology offers a great way to augment your team’s effectiveness, whether it’s analyzing coding for potential issues or prioritizing/routing suspect cases to the appropriate resource for additional review.

3. Office of Inspector General (OIG) audits of telemedicine services.

The OIG recently announced it will start auditing telehealth services in 2021. Audits will focus on pandemic-related waivers and flexibilities that allowed Medicare beneficiaries to access a wider range of telehealth services without having to travel to a healthcare facility. Given the increased volume of telemedicine services during COVID-19, this could be an area of intense vulnerability for many healthcare organizations. Without strict oversight, it’s easy for mistakes to be overlooked and perpetuated across thousands and thousands of claims, putting substantial revenue at risk.

Action item: As stated previously, the goal is to prevent errors before claims even go out the door. Pre-bill technology can greatly assist organizations in achieving this, using a combination of automated analysis and custom rules targeting the unique requirements needed to qualify for telehealth reimbursement.

4. Sweeping changes to evaluation and management (E/M) codes, guidelines.

As of January 1, 2021, organizations will have to accommodate another curveball from CMS. Physicians will transition to using a new set of E/M guidelines that require code assignment based on time or medical decision-making (MDM). To bill based on time, physicians must document the total time spent on the date of the encounter. This includes face-to-face and non-face-to-face time. Interestingly, the 2021 changes eliminate the requirement that providers must spend more than 50% of the encounter counseling the patient and coordinating care. There’s also a new MDM table that’s more prescriptive about the quantity of data ordered or reviewed.

Action item: Audit documentation, educate physicians, and contact EHR vendors to ensure their systems are ready for these changes on January 1st.

“By leveraging pre-bill technology, organizations can augment existing staff’s productivity and judgment. They can automate key processes so coders and auditors focus more time and energy delivering cognitive value.”

How pre-bill technology can help

Each of these regulatory changes collectively highlight one important point: Organizations can’t be complacent. They can’t get ‘too comfortable’ with their processes because as soon as they do, there’s a new regulation to unpack and operationalize. They need a strategy that can easily grow and scale with these changes as they occur—not months down the line after denials start pouring in and RAC notices start arriving.

Is it realistic to hire more staff who can review claims manually to ensure compliance? Not likely. Staff bandwidth is a fixed resource, but technology can be leveraged to increase your staff’s efficiency and efficacy.

Pre-bill technology like automated coding analysis gives organizations the ability to review all claims—not just a small sample size. Organizations can also customize and add new rules as regulations change, giving them the ability to proactively confirm compliance as quickly as possible. By leveraging pre-bill technology, organizations can augment existing staff’s productivity and judgment. They can automate key processes so coders and auditors focus more time and energy delivering cognitive value.

Regulatory change will never go away, but you can prevent the disruption and uncertainty it brings. It’s time to explore how pre-bill technology can help today’s healthcare organizations survive and thrive in a regulatory-driven environment.

See for Yourself

As more providers are discovering, pre-bill technology is the key to optimizing revenue integrity and financial performance across all service lines. As the leader in solutions to optimize coding accuracy prior to billing, Streamline Health is helping providers establish a new normal that improves their bottom line despite these challenging times. To discover how we can improve coding accuracy and financial performance for your organization, contact Streamline Health today.