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