Updates from your ACE team
As you closed the books on 2019 and reviewed numbers from the final quarter and year and planned for 2020, the thought of the amount of money left on the table and how to reduce that number possibly crossed your, and definitely your CEO's and CFO's, minds. This edition, we focus on denial rates and the most common causes, why you want to avoid them and tips and tricks on how to avert them. We also focus on your front desk team and the importance of ensuring they are up to date on their training and how they can influence and prevent your denial rate. Finally, this edition highlights another RCM solution that can increase your revenue: retro pay.
Rejections and denials are so last year
It can be problematic for you when your claims are denied or rejected. Rejected and denied claims may cause your A/R to increase. However, claims may be rejected or denied due to several controllable and uncontrollable factors. It is best practice and our recommendation that you investigate why the claim was denied or rejected, correct it before resubmitting it to the payer and train the department that caused the error.

When your denied claims are not handled well your facility: does not receive reimbursement for the services provided, may experience an increase of unnecessary write-offs and/or a loss of productivity due to your team members following up on previous payments instead of working new claims and/or an increased cost per claim. These results, individually or altogether, cause your bottom line to suffer.

For 2020, what would your revenue look like if you didn't have rejections and denials? We have six tips and tricks to help you increase your percentage of "clean" claims and improve your bottom line:
  1. Capture patient information upfront
  2. Verify eligibility and benefits
  3. Check the information's accuracy
  4. Understand payer policies
  5. Use correct coding
  6. Avoid duplicate billing
Medical billing's "passive" income
Another way to drive your revenue is through retro pay .

Your facility probably sees it every day; self-pay and charity patients come through the office and unfortunately cannot afford their visit. Days, weeks, or even months later they become eligible for Medicaid. Most billing departments don't track their past patient's eligibility for various reasons - there's more money to capture today or the department doesn't have a team dedicated to tracking the patients months after their visit. However, those billing departments will never know whether or not they can bill Medicaid for that patient's visit, which translates to money left on the table.

How can we help ensure you receive this reimbursement? We continuously monitor your self-pay encounters for the duration of its eligibility (days, weeks, months), identify your population of patients that qualify for the program, bill the appropriate payer (Medicaid) and collect the maximum reimbursement amount... which goes toward your bottom line.
What are the new CMS rules again?
Do you remember all the 2020 rules CMS proposed November 2019? A lot has happened since then, so here's a quick crash course:
  1. CMS changes the fee schedule: CMS will increase the CY 2020 PFS conversion factor by $0.05.
  2. CMS backpedals on changes to E/M visit payments: CMS, due to provider push back and the American Medical Association (AMA), will be moving from last years semi-blended approach back to the five-tier payment system for E/M visits. This change back will not be effective until January 2021. 2020 will continue with 2019's rules.
  3. CMS finalizes changes to help the opioid crisis: CMS expanded Medicare coverage for opiod use disorder treatment service through several new policies, including bundled payments, new telehealth services and medication-assisted treatment (MAT) coverage.
  4. CMS raises the performance threshold for QPP, transitions to MVPs: CMS finalized a proposal to increase the minimum number of points clinicians must receive to avoid a negative payment adjustment under QPP's Merit-based Incentive Payment System (MIPS) to 45 points for 2020. This will increase to 60 points in 2021. According to CMS, providers under MVPs will no longer report on MIPS' performance categories - quality, cost, improvement activities and promoting interoperability - and will instead report on a reduced set of measures that are more closely aligned with alternative payment models (APMs), outcome-based and specific to a clinician's specialty or a given condition.
  5. CMS increases payment for transitional care management and expands the scope of PA's: CMS will now pay clinicians for care management services for patients who have a single high-risk medical condition, such as diabetes and high blood pressure. CMS created a new add-on code to pay clinicians for additional time spent on care management activities for patients with multiple chronic conditions. Additionally, PA's may now practice more broadly to care for patients.
Media watch and other useful info
CMS spent 2019 working to transform health care by making visits a better experience for providers and patients.

On the patient side, CMS worked with them to see how it could provide patients better value and results. Check out CMS' 16 strategic initiatives.

CMS realized that it couldn't improve the patient experience without also closely working with providers. CMS worked closely with providers to decrease their amount of "red tape." The reduction of the red tape allows physicians more time to treat their patients and deliver quality patient care instead of spending the majority of their time on paperwork. This change improved the patient and provider experience.

CMS is going to continue to strengthen its program policies that rewards providers for their high-quality treatment plans. This program will be in full effect in 2021.
The snapshot of 2020 payment adjustments for the Merit Based Incentive Payments System (MIPS) Eligible Clinicians states:
  • 84% will receive an additional adjustment for exceptional performance.
  • 13% will receive a positive payment adjustment.
  • 0% will receive a neutral adjustment (no increase or decrease).
  • 2% will receive a negative payment adjustment.

CMS will be supporting the providers in small practices to make them more successful. CMS will provide technological support through its no-cost, small, under served and rural support initiative. The assistance is available to practices with 15 or less clinicians, including those located in: rural areas, designated health professional shortage areas (HPSAs) and medically underserved areas (MUAs). Facilities are considered a priority if they are located in a rural area, HSPAs, or MUAs.

Good news! Tweens and teens' misuse of prescription medications, alcohol, tobacco cigarettes continues to decline. The bad news is that 8th and 10th graders have increased their daily use of marijuana and tobacco via vaping. This demographic's "[attraction] to vaping products threatens the years of progress [of] protecting adolescents' health," said NIDA Director Dr. Nora Volkow.
Click HERE for the infographic of overall findings and HERE for the vaping infographic.

Are you prepared to help those tweens and teens kick their bad habit to the curb?

On January 7, 2020 HRSA emailed a reminder of all the new polices posted throughout 2019. The new policies include 340B pharmacy. Click HERE to ensure you are up to date with HRSA's guidelines.

HRSA recently completed an audit of Xspire's participation in the 340B program. Both parties determined Xspire did not offer statutory 340B ceiling prices for its covered outpatient drugs between 8/1/2012-8/1/2019. Xspire requests that any covered entity that purchased its drugs during that time submit the appropriate requests, as defined, for refund by 3/31/2020. For more information click HERE.