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Practice Management

What the Strike Down of Chevron May Mean to HIM Professionals

On June 28, 2024, the Supreme Court unraveled the 1984 decision, Chevron v. Natural Resources Defense Council . Chevron has been one of the most cited decisions in American law, because it granted significant power to executive agencies that regulate many aspects of our lives and work.

The ruling will make it easier to challenge regulations across an array of issues, like keeping the water clean; ensuring car seats are safe; what Medicare covers including NCDs/LCDs; and CMS regulations related to billing and coding (for example, will we use ICD-9, 10, or 11?); and even regulations associated with EMTALA and utilization review.

Legal challenges at the federal levels have relied on Chevron to defuse and dismiss challenges to regulations. According to the precedent established in Chevron , if part of the law Congress wrote empowering a regulatory agency is ambiguous but the agency's interpretation is reasonable, judges should defer to the agency.

In the New York Times, “How a Fishery Case Fits Into a Long-Game Effort to Sap Regulation of Business” (Jan. 17, 2024), Charlie Savage contends that critics of Chevron argue that Chevron put too much power in the executive branch when the courts are competent to interpret the law. Proponents of Chevron counter-argue that without the agency regulations, courts may be overwhelmed and dealing with many technical issues that judges have no expertise to resolve.

We need to make a distinction here. Regulations and interpretations are issued after a law or statute is established. Chevron and its demise are placing regulations and interpretations on the table for questioning.

Savage also reported that Jody Freeman, a Harvard University law professor who specializes in administrative and environmental law, suggested that the rejection of Chevron will create “a free-for-all for judges to dig into the nitty-gritty of everything agencies are doing” and “an invitation for interest-group lawyers to try to tie up the agencies in legal knots.” In contrast, as reported by the HFMA in “Supreme Court Ruling on Chevron Makes Regulations in Healthcare More Vulnerable to Legal Challenges” (June 28, 2024), the Supreme Court stated that “Courts must exercise their independent judgment in deciding whether an agency has acted within its statutory authority. Courts are in a better position to resolve the statutory ambiguities.”

One, if not the first, lawsuit was filed in Mississippi, with the court issuing an injunction on July 3, 2024, on behalf of 15 state Medicaid agencies, preventing the Biden administration from enforcing regulations expanding anti-discrimination gender specific protections in the Affordable Care Act (ACA). In this case, reported by the HFMA in “HHS Issues Regulations to Strengthen Anti-Discriminatory Protections in Healthcare” (July 3, 2024), according to the Mississippi Court, the relevant laws—that is, statutes-are Title 9 and ACA, and neither mentions gender identity.

Many agency interpretations could now be out and the courts' decisions in , which means that statutes trump regulations.

Although not identical in nature, think about what has happened in the courts since Roe v. Wade was struck down. Now, let's consider what the Chevron decision might mean for coding and billing guidelines that will be on the table for payors to litigate the validity of, and how the guidelines may be modified in each court. Could we end up with guidelines that are not just payor-specific but also state-specific?

John Hall, MD, JD, mentioned on Monitor Mondays (July 8, 2024) that we have 94 federal courts. Texas has four and could therefore have four different decisions on the same agency interpretation!

The HFMA shared a perspective that hospitals that disagree with CMS's application of the market basket in its annual determination of Medicare payments or covers an item or service or not, could litigate and successfully argue the issue. Specifically, “There are thousands of pages of regulations and manuals containing agency interpretations of program requirements such as coding for risk adjustment payments, qualifications for disproportionate share hospital payments, [and] supervision requirements for use of physician extenders…”

Within those stacks of agency interpretations and regulations will be such regulations as: coding for HCCs, what should be in an H&P, the two-midnight rule, billing rules, E/M requirements, what constitutes a complete record, and so on. Consider just the HIPAA requirements: Could attorneys litigate what is PHI and what isn't, how much/if anything should be charged for copies, and who may access the record?

One suggestion offers a workaround employing negotiated rulemaking, a process in which a committee of agency experts and affected parties collaborates on proposed regulations. Reported by Polsinelli in “The Chevron Doctrine: Part 1” (May 2, 2024), “Although negotiated rulemaking is not appropriate for all regulations, advocates have felt the approach can speed rule development, reduce litigation, and generate more creative and effective regulatory solutions. Congress has sometimes mandated negotiated rulemaking and established specific procedures and time frames to follow.”

What actions should revenue cycle and health information professionals take?

• Review and understand the rationale behind the specific coding rules that you may be using for appeals. Just citing agency interpretations and guidelines may no longer suffice and could be ignored by payors. If an appeal goes up the judiciary ladder, coding professionals and denial specialists will need to argue the rationale of the code applied and even the sequencing of those codes.

• Capture and compare the application of payor coverage rules for similar patient populations and the payors' billing requirements to define the industry norm. Again, payors may use the demise of the Chevron rule to apply their own billing requirements. In court, you and your attorneys may need to promote the norm and defend against using willy-nilly requirements. Imagine having to configure the organization or practice's billing and edit systems for each payor's application of the standard billing rules. Explaining the technological challenges to modify a billing system to accommodate rules that are unique to a single payor for the services being claimed for a commercial, Medicaid, or Medicare patient will benefit the organization should it file or be a party to a lawsuit against a payor.

• Proactively convene functional leaders from those functions that are substantially governed by agency regulations. This includes finance, compliance, health information, coding, revenue cycle, payroll, pharmacy, laboratory, etc. to forecast “what ifs” and identify issues that are controversial or vulnerable to litigation because they are based on agency rules, such as whether and how much you can charge for copies of records, what is considered protected health information for individuals participating in research, what needs to be in a compliance plan, what if the inpatient only list is challenged, should CISA requirements for cybersecurity protections be followed, and so forth. Any of these are possibilities now that Chevron has been struck down.

• Communicate with our congressional members and encourage the use of negotiated rulemaking. And, at the same time, urge each of our professional associations (such as AHIMA, HFMA, HIMSS, and AAPC) to get involved now .

I encourage readers to review the articles that are cited herein as these authors provide great insight; another recommended resource is Adam Liptak's “The Morning: A Landmark Case. How Much Power Should Government Experts Have?” (Jan. 18, 2024) in the New York Times.

To all of us: Be ready for the litigation heyday ahead.

Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, FAHIMA, is a past president and former interim CEO of AHIMA and recipient of AHIMA's distinguished member and legacy awards. She is Chief Operating Officer of First Class Solutions, Inc. sm , a healthcare consulting firm based in St. Louis, MO. First Class Solutions, Inc. sm assists healthcare organizations to enhance or transform their HIM operations, facility and physician office documentation, and revenue cycle performance, and provides coding support and coding audits. Rose is also the author of Libman's HCC Fundamentals and Auditing programs.

(Note: This article was first published July 8, 2024, and is being made available with permission to republish granted by ICD10monitor.)

Practice Management

Navigating the Storm: Key Strategies for Effective Denials Management in Healthcare

Practice Management

MedRhythms Secures New Reimbursement Code for InTandem Stroke Rehabilitation System

Practice Management

CrowdStrike Update: Faulty Sensor Software Update Causes Widespread Windows Crashes

Practice Management

Coming Soon to a Federal Register Near You: Changes to the FTC’s Health Breach Notification Rule

Practice Management

Empowering Healthcare Staff with Comprehensive Training:In the field of healthcare, the importance of a well-trained and skilled workforce cannot be overstated. As the backbone of medical practices, healthcare staff members hold the key to delivering quality patient care and ensuring smooth operations.

Practice Management

A Dedicated Advocate for Public Service and Whistleblower Protection:Whistleblowers are vital to the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), playing a pivotal role in fighting health care fraud and ensuring integrity in health programs. Their courage to speak out protects public trust and the effective use of government resources.

Practice Management

At AHIP 2024, A Firm Focus on Healthcare’s Future Challenges and Opportunities:Ensuring the U.S. public health infrastructure is ready to meet the challenges of the future was the pervasive theme at June’s AHIP 2024 conference. Sheltered from the desert heat inside Wynn Las Vegas, AHIP attendees discussed how our country can implement a vision of healthcare that is equitable, accessible, and affordable.

Practice Management

Asynchronous Telehealth and Patient Privacy:Telehealth refers to a collection of methods to enhance healthcare delivery and education—it’s not a specific service.

Practice Management

How Providers Can Use AI to Win More Claims Denial Appeals:Healthcare providers face so many concurrent financial challenges, including rising costs, labor shortages, and constrained capacity, that the amount of time and money they must expend on appealing claim denials is particularly galling.

Practice Management

Overcoming Prior Authorization Challenges With Technology:The latest survey from the American Medical Association (AMA) reveals the significant challenges posed by prior authorization in healthcare. Prior authorization, a process insurers use to manage healthcare utilization and control costs, often disrupts patient care, burdens physicians with administrative tasks, and wastes healthcare resources.

Practice Management

6 Best Practices for Seamless Clinical Data Integration:Clinical data integration refers to the collection of information from various medical departments, third-party vendors, and payers, and to enable seamless data exchange. An integrated healthcare organization has the power to improve the quality of care and streamline workflows.

Practice Management

What Is the Goal of Revenue Cycle Management?:All healthcare practices are focused on the same thing: achieving the best possible outcomes for their patients. It also requires paying attention to the business side of the healthcare practice–after all, if your practice is routinely running into cash flow issues and struggling to get paid on time, it's going to be that much harder to accomplish your goals without a strong revenue cycle management system.

Practice Management

SYNERGEN Health welcomes highly experienced CFO Jolene Varney to its Advisory Board:SYNERGEN Health, an industry-leading provider of technology-enabled revenue cycle services and solutions for healthcare organizations, today announced the appointment of Jolene Varney to the SYNERGEN Health Advisory Board.

Practice Management

Physician Compensation Models and Expenses:One of the most important decisions that a growing medical practice must make is how to compensate its providers. When a practice has only one provider, the compensation model is very simple. Revenue is received, expenses are paid, and any funds remaining are paid to the owner. However, when new providers (whether they are associates or partners) join the practice, the compensation model suddenly becomes more complex.

Practice Management

Outsourcing Medical Billing Can Minimize Claim Denials and Maximize Reimbursement:For any kind of practice, an efficient medical billing process is essential to ensure smooth submission and follow up on medical claims. When it comes to receiving timely payments, accurate billing and coding are key. Accuracy also ensures that patients are billed correctly and fairly. A growing number of practices now rely on medical billing outsourcing to ease the cumbersome billing process, avoiding claim denials and maximizing reimbursement.

Practice Management

Five Critical Comparisons to Evaluate AI in RCM:As Artificial Intelligence (AI) picks up momentum in healthcare, leaders in Revenue Cycle Management (RCM) are often at the forefront of decision-making—wading through technical assessments and vendor evaluations in an effort to determine the best partner for their billing and coding needs.

Practice Management

The Cobra Effect: A Study in Laws of Unintended Consequences:Every decision or action we make carries unintended consequences. The “cobra effect” is a term coined for a solution that makes a current problem worse based on incentives, rewards, and/or punishments—exposing chinks in the planning. Perverse incentives are nearly natural by-products, motivating unscrupulous individuals to game the system to make easy money or cut corners in regulations.

Practice Management

How to Improve Your Accounts Receivable (AR) in Healthcare:Managing accounts receivable (AR) is crucial for healthcare providers to ensure steady cash flow and financial stability. However, navigating the complexities of AR can be challenging, especially with insurance claim denials, delayed reimbursements, and other roadblocks. This article discusses practical strategies and best practices to improve your accounts receivable in the healthcare industry, helping you optimize revenue cycles and enhance overall financial performance.

Practice Management

Coverage Transparency and the Role of Fiduciaries:Investopedia states “A fiduciary is a person or organization that acts on behalf of another person or persons, putting their clients' interests ahead of their own, with a duty to preserve good faith and trust. Being a fiduciary thus requires being bound both legally and ethically to act in the other's best interests. A fiduciary may be responsible for the general well-being of another (e.g., a child's legal guardian), but the task often involves finances-for example, managing the assets of another person or a group of people. Money managers, financial advisors, bankers, insurance agents, accountants, executors, board members, and corporate officers all have fiduciary responsibility.”

Practice Management

Considerations for Whistleblowers and Companies:In June 2022, I wrote an article, “The False Claims Act and the Seal: What Whistleblowers Need to Know,” which I encourage everyone reading this article to also read. The United States Supreme Court’s decision in United States ex rel. Polansky v. Executive Health Resources (599 U.S. 419; 2023) confirmed that the United States government has nearly unfettered discretion “to dismiss a [federal False Claims Act] suit over a relator’s objection” (Id. at 423; see also State ex rel. Fox v. Thornley, 2023 IL App [4th]; citing Polansky as instructive when interpreting the Illinois False Claims Act).

Practice Management

Regulatory Issues Facing Radiology Groups in 2024:We pay a lot of attention to government regulation in healthcare, especially the Medicare Physician Fee Schedule (MPFS) that influences reimbursement not only from Medicare but also from other payors since many commercial contracts are tied to the MPFS. Although it is the object of most focus, the Centers for Medicare and Medicaid Services (CMS) is not the only agency that regulates healthcare.

Practice Management

Top Five Ways Medical Practices Can Combat Inflation:Inflation is affecting many businesses, but medical practices tend to see the brunt of its effects because of the way payment structures are dictated by insurance payers. Even more worrisome, practices have had to increase wages significantly and the current job market tends to favor employees. In some instances, employees are asking for wages 20-30% higher than previous, and understandably can command these wages as there is fierce competition for skilled employees. While these issues are affecting many businesses, there are things medical practices can do to help ease the squeezing margins.

Practice Management

Everything You Need to Know About the CMS-HCC-V28 Changes and How AI Helps:A new year brings excitement, fresh starts, and the latest changes to the CMS-HCC (Centers for Medicare and Medicaid Services hierarchical condition category) risk adjustment model, version 28 (V28). And even if you're excited about 2024, the guideline updates are probably stressful and a bit deflating. It can take months for coding and revenue cycle teams to get up to speed with the latest updates, and the training and accompanying expenses – as well as the inevitable mistakes that come with any coding update – cause billing delays, underpayments, and claim denials. Most healthcare organizations likely still have last year's evaluation and management changes for emergency departments fresh on their minds. Will you experience the same struggles again with CMS-HCC-V28?

Practice Management

Thoughts Had ... Lessons Learned - U.S. Healthcare Challenges :Congratulations to the BC Advantage team for 19 years of successfully making a positive difference in the healthcare industry and for supporting those of us who earn our living in this industry.

Practice Management

The Stability Factor: Documenting Chronic Exacerbated Conditions:I have been in the healthcare field for more than 35 years, and remember when we didn't have Evaluation and Management (E/M) codes. Then, we went through the 1995 and 1997 guidelines from CMS. All the elements, boxes, borders – UGH! Now, we have a cleaner way to document E/M services with the 2021 and 2023 updates.

Practice Management

The Uniform Commercial Code and Its Relation to Hardware, Software, and Related Services Used by Healthcare Sector Participants:As set forth in 45 CFR § 164.502(a)(3), a business associate may not utilize protected health information (PHI) in any way that would violate the Health Information Portability and Accountability Act of 1996 (HIPAA) and the related Privacy Rule.

Practice Management

Monthly Spotlight on Fraud, Waste, and Abuse:The following cases highlight fraud, waste, and abuse (FWA) and serve as a reminder to uphold high ethical standards when providing patient care and services.

Practice Management

Unlocking Revenue Potential: How Data Analytics Powers Smarter Revenue Cycle Management:In today's ever-evolving healthcare landscape, the pursuit of unlocking the full revenue potential of healthcare organizations stands as a paramount objective. With healthcare costs rising and the intricacies of medical billing becoming increasingly complex, the need for precision and insight in managing revenue has never been more critical. Data analytics has the transformative power in revenue cycle management to shed light on the strategies, tools, and real-world successes that can guide healthcare providers toward financial clarity and success.

Practice Management

Data Use Agreements: Utilization and Distinguishing from Business Associate Agreements:Any person in the healthcare industry knows or should learn that if they are considered a covered entity or business associate (including subcontractor), that creates, receives, maintains, and/or transmits protected health information (PHI), then a business associate agreement (BAA) is required. See 45 CFR §160.103, 45 CFR § 164.504. This is not a new phenomenon; in fact, it has been required for over 20 years.

Practice Management

Tomorrow's Doctors: Evolving Trends in Healthcare Specialty Training:If you're in healthcare or aspiring to be, specialty training is where the rubber meets the road. It's the bridge from general medical knowledge to honed expertise in a particular field. You've probably caught wind of how specialty training in healthcare is not what it used to be. New tech, evolving patient needs, and a myriad of other factors are reshaping the landscape. As healthcare evolves with technology and societal needs, specialty training is undergoing a metamorphosis, aiming to create professionals who are adept at both traditional and modern healthcare practices.

Practice Management

Medical Practice Relocation Tips for Moving to a New Location:Roughly 40 million Americans relocate each year. In 2022 alone, the U.S. Postal Service processed over 33 million change-of-address forms. However, people aren't the only ones capable of moving – businesses can, too. If you are a healthcare provider in private practice that has decided to relocate your medical practice, the process will involve a lot more than a change-of-address form!

Practice Management

Decoding the Maze: Navigating Prior Authorization in Healthcare (Part 1):Picture this: You're at a hospital, and amidst the stress of an upcoming procedure, you're swamped with paperwork and concerns about the treatment's financial aspect. This scenario is all too common, and at its core often lies the concept of prior authorization.

Practice Management

Whistleblowers and Company Data: To Collect or Not to Collect:Before the thought, "Oh, I have access to all this information - ‘Come on Barbie, let's go party' 1" crosses a potential whistleblower's mind, there is one question to ask. "Should I collect documents from my employer or a person that I contract with to perform services?" This is critical to avoiding potential liability at both the employment and post-employment stages. What are the potential ramifications? It depends.

Practice Management

Choosing the Right Deductible:Often and easily forgotten is that the producer's role extends beyond simply selling insurance policies. Top shelf producers are trusted advisors not only to their clients, but carrier partners, as well. This article will focus on serving the employer. In this capacity, the producer may act as an extension of the employer's HR, finance, and executive departments. This may include advising on industry trends, policy updates, and emerging healthcare issues.

Practice Management

The American Healthcare System: A Problem in Need of Solutions:The United States spends more on healthcare than any other country in the world, yet it has some of the worst health outcomes. This is due in part to a number of problems with the American healthcare system, including:

Practice Management

Decoding the Maze: Navigating Prior Authorization in Healthcare:Picture this: You're at a hospital, and amidst the stress of an upcoming procedure, you're swamped with paperwork and concerns about the treatment's financial aspect.

Practice Management

Redefining Healthcare: An Exploration of Automation in the Digital Transformation Journey:In an era where digital technologies are transforming industries at an unprecedented pace, healthcare is no exception. The sector is undergoing a significant shift, driven by innovations that aim to enhance care delivery, improve patient outcomes, and reduce costs. Central to this digital transformation narrative is automation. This article will delve into the role of automation in redefining healthcare, exploring its significance and potential to shape the future.

Practice Management

Emotional Support Animals:An Emotional Support Animal (ESA) is a pet, prescribed by a licensed provider to a patient for their mental health, which provides emotional support to the individual. ESAs can be different types of pets, most commonly dogs and cats, and any age or breed. What they all have in common is they comfort their owners with companionship and improve their quality of life.

Practice Management

2024 Guide: 13 Steps of Revenue Cycle Management:In the ever-evolving world of healthcare, revenue cycle management (RCM) plays a crucial role in the success of any medical practice. Efficient RCM ensures timely and accurate payment for services rendered, which can significantly impact the financial health of a practice.

Practice Management

HHS Selects the First Drugs for Medicare Drug Price Negotiation:For the first time, Medicare will be able to negotiate prices directly with drug companies, lowering prices on some of the costliest prescription drugs.

Practice Management

ApolloMD Leverages Fathom Autonomous Medical Coding to Save Costs and Accelerate Revenue Cycle for 1,500+ Physician Group:Fathom's AI-based automated medical coding delivers industry-leading automation rates with improved accuracy, reducing ApolloMD's coding costs and alleviating coding staffing challenges

Practice Management

The Role of Artificial Intelligence in Revolutionizing Medical Billing Services for Physicians:In today's rapidly advancing healthcare landscape, medical billing has become a critical aspect of running a successful medical practice. Efficient and accurate billing processes are essential for healthcare providers to receive timely payments for their services. With the advent of artificial intelligence (AI) technology, medical billing services have undergone a revolutionary transformation. This article explores the role of artificial intelligence in revolutionizing medical billing services for physicians, highlighting the benefits and advancements brought about by this innovative technology.

Practice Management

Navigating Carrier Guidelines for Optimal Practice Reimbursement:When a Medicare patient has multiple sources of insurance coverage, Medicare will only pay for services after the primary payor has processed the claim and made their payment. Medical office staff must always verify the patient's insurance coverage thoroughly-gathering all necessary information from the primary insurance, such as policy numbers, claim submission instructions, and any preauthorization requirements, etc.

Practice Management

The Evolution of MIPS and Understanding the Upcoming Changes:In the world of healthcare, the Merit-Based Incentive Payment System (MIPS) plays an instrumental role in incentivizing providers to deliver high-quality, efficient patient care. However, staying up to date with MIPS can be a challenge as the program is subject to continuous changes and updates.

Practice Management

Proposed Rule for Medicare Physician Fee Schedule CY 2024 Sees Continued Decrease in Reimbursement:The Medicare Physician Fee Schedule (MPFS) Proposed Rule (PR) for Calendar Year (CY) 2024 was released on July 13, 2023. The PDF is available for review. Public comments are accepted for a sixty (60) day period through September 11, 2023.

Practice Management

Monthly Spotlight on Fraud, Waste, and Abuse:A physician was sentenced to two and a half years in prison for fraudulently obtaining and misappropriating approximately $250,000 from two separate COVID-19 relief programs.

Practice Management

Texas HHSC-OIG is Ramping Up Its Investigations of Medicaid Pediatric Telemedicine Claims:In the state of Texas, Medicaid plays a significant role in providing healthcare services to a large portion of the population. With more than 5.9 million Texans1 (approximately 18.9% of the current population2) enrolled in Medicaid, it is an essential program for qualifying low-income citizens. In Texas, Medicaid costs taxpayers over $40 billion.

Practice Management

Seven Reasons to Standardize Medical Records:The electronic health record (EHR) is widely used for documenting and managing the patient's medical record. In the 1980s, the first web-based EHRs were being introduced and used in healthcare facilities because computer hardware had finally become affordable.

Practice Management

ERISA - Overview for Healthcare Providers: Part I:In the United States, approximately 88% of the employees who are enrolled in employer-sponsored health insurance benefits have plans that are subject to ERISA regulations.

Practice Management

Becoming a Resilient Leader During Trying Times:Resilience is the ability to confidently face challenges, embrace change, recover from setbacks, and bounce back from adversities. This can be extremely difficult for leaders in today's healthcare environment. Increasing your resilience is easier said than done, especially post-COVID. This article provides insight to managers on how to succeed in a competitive, challenging industry.

Practice Management

The CERT Program: What It Is and What a Practice Needs to Know:The Comprehensive Error Rate Testing (CERT) program is a crucial component of the Medicare program that helps ensure the government is paying only for the services and care that beneficiaries actually receive. The program is designed to identify improper payments made to healthcare providers and suppliers under Medicare Part A and B and Durable Medical equipment MACs (DMACs). This article will explore what the CERT program is, how it works, what a practice should do if a CERT request for records arrives, and how the CERT report can be used to help a practice stay compliant.

Practice Management

Harness the Power of Patient Reviews to Elevate Your Practice:When was the last time you made a purchase without looking at product and service reviews? Amazon, Facebook, Google, Netflix, Uber, Travelocity - powerhouse, world-changing organizations all built upon the culture and value of reviews. Healthcare is not immune to the review culture; with our consumerized patient, positive public sentiment is liquid gold and one of your most valuable assets! In fact, 86% of top performing healthcare providers are asking for reviews and feedback after every patient encounter.

Practice Management

Transforming Rural Healthcare Delivery: The Mission and Vision of the Office of Rural Health:For many rural communities, accessing quality healthcare remains a challenge. Geographic isolation, insufficient medical facilities, and a lack of specialized care providers can create significant barriers to adequate care. Recognizing these issues, the Office of Rural Health was established with the goal of improving healthcare in rural areas. This article will explore the mission and vision of the Office of Rural Health and discuss how its initiatives are transforming rural healthcare delivery.

Practice Management

Part 1: Basics of Artificial Intelligence (AI) and Healthcare Compliance:Artificial intelligence (AI) technology has created new opportunities to progress on critical issues, such as health, education, and the environment. In some cases, AI may do things more efficiently or methodically than humans.

Practice Management

Freestanding Emergency Center (FEC) Industry Lobbying Goes to Washington:In early February, members of the National Association of Freestanding Emergency Centers (NAFEC) went to Washington D.C. to meet with various members of Congress to gain support for two items: the continued recognition of Freestanding Emergency Centers post pandemic and for oversight of the No Surprises Act Independent Dispute Resolution process.

Practice Management

The Significance of Not Obtaining Patient/Consumer Consent Before Poaching Data:Now, in 2023, the FTC announced two consent orders related to the prohibited poaching and use of PHI by known third parties and the DOJ announced another settlement under its Civil Cyber-Fraud Initiative.

Practice Management

Seven Measures Developed by the HHS Office of Inspector General (OIG) to Identify Potential Telehealth Fraud:n September of 2022, the Office of Inspector General (OIG) released a report, "Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks," in which they identified that approximately two in five Medicare beneficiaries used telehealth services within the first year of the pandemic to receive healthcare services from a Medicare provider. This is approximately 88 times more often than beneficiaries engaged through telehealth services prior to the pandemic.

Practice Management

The Crucial Role of Negotiating Payer Contracts Every 18 Months for Physician Offices:The healthcare landscape is constantly evolving, with changes in technology, patient care, and the business of medicine all occurring at a rapid pace. One area that is often overlooked but is equally critical to the success and sustainability of a medical practice is the negotiation of payer contracts.

Practice Management

Revenue Cycle Challenges: The Financial Savior:As consumers, we all face challenging inflationary pressures in our lives, with everything presenting challenges to our budgets. Essential groceries and other items are up significantly, posing tremendous financial obstacles for all consumers. The Consumer Price Index (CPI), a closely watched gauge of inflation, recently showed that price increases continue to slow.

Practice Management

Is the Violation Right of Access or Information Blocking? Do You Know the Difference?:The right of access and information blocking are both related to the access and exchange of health information, but they are different in several key ways. HIPAA Privacy/Security and Compliance Officers and Health Information Management professionals need to know the difference. It is important to differentiate between Right of Access and Information Blocking to ensure your organization is compliant with both rules, as well as any applicable state privacy regulations.

Practice Management

Healthcare Compliance: A Unique Opportunity to Impact the Business Side of Medicine:I have been privileged to make my entrance into the world of healthcare, in medical coding, specifically after my first career as an art historian dissolved way back in 2008 due to the recession. Mind you, I have taken all my research skills, writing, communication, and critical thinking strengths along for the ride.

Practice Management

Overcoming Self-Pay Challenges in Revenue Cycle Management:Amid the headlines of labor shortages and hospital closures, many Americans may have missed some positive recent healthcare-industry news: The U.S. reached a new, all-time low in the rate of Americans without health insurance.

Practice Management

FY24 IPPS Proposed Rule Boosts Hospital Payment Rates by 2.8%:CMS proposed a new rule for the fiscal year 2024 Inpatient Prospective Payment System (IPPS), increasing hospital payment rates up to 2.8%. Also, the newly proposed IPPS rule adopts policies that are aimed at advancing health equity.

Practice Management

Empowering Your Front Desk Staff to Improve your Revenue Cycle Management :The front desk is the first point of contact for patients visiting a healthcare facility, and it plays a crucial role in revenue cycle management. The front desk staff is responsible for managing patient registration, insurance verification, appointment scheduling, and collecting payments. Empowering your front desk staff can significantly improve your revenue cycle management and boost your bottom line.

Practice Management

Spotlight on Fraud, Waste, and Abuse - March 2023:The following cases highlight fraud, waste, and abuse (FWA) and serve as a reminder to uphold high ethical standards when providing patient care and services.

Practice Management

12 Tips to Grow Your Medical Practice in 2023:Do you want to expand your medical practice without collapsing? Here are 12 realistic tips to safely and effectively grow your practice in 2020.

Practice Management

The Importance of Selecting the Right EMR and PMS Software:As a healthcare organization, choosing the right electronic medical record (EMR) and practice management system (PMS) software is critical for the success and efficiency of your operations. The right software can streamline patient care, improve data accuracy and security, and reduce administrative burdens, among other benefits.

Practice Management

Recent False Claims Act Cases Shed Light Upon Compliance Scrutiny:As touted by the U.S. Department of Justice (DOJ) and Members of Congress alike, including Senator Chuck Grassley (R-IA), the False Claims Act, 31 U.S.C. §§ 3729, et seq. (FCA) is the federal government's primary tool to root out fraud and put money back into the federal fisc.

Practice Management

Consensus Cloud Solutions to Showcase Healthcare Technologies that Enhance Interoperability at ViVE 2023:Consensus Cloud Solutions, Inc. (NASDAQ: CCSI), the world's largest provider of digital cloud fax technology, will be exhibiting their suite of interoperability solutions at the ViVE 2023 conference in Nashville, Tennessee, March 26-29th. Booth #1020

Practice Management

Five Steps for Provider Credentialing:When your facility hires a new provider, they need to be credentialed. This process allows you to verify their qualifications and skills while getting them approved to work with insurance companies. Medical credentialing is a time-consuming and expensive process that requires complete concentration by a professional. This can use a lot of your facility's resources.

Practice Management

5 Ways in Which Healthcare Data Visualization is Transforming Healthcare:

Healthcare providers can make use of data visualization to assess past and present medical history and improve patient care and outcome.

Practice Management

The End of the PHE: Medicaid, The Omnibus Act, and What Hasn't Been Addressed:An announcement on January 30th, by the OMB (Office of Management and Budget) and the White House, stated that they plan to end the COVID-19 national emergency and public health emergency on May 11th.

Practice Management

Three Ways Medical Groups Can Leverage Digital Self-Service to Drive Growth:That medical groups and health systems share a commitment to delivering convenient, high-quality care in their respective settings isn't surprising. What is eye-opening, however, is that despite their differences in size and structure, they face many of the same business challenges, such as fending off market competitors, acquiring and retaining patients to ensure profitability, and working to alleviate staff burnout.

Practice Management

How to Establish a Business Plan for Your Holistic Practice:Opening a holistic healthcare practice is an exciting and challenging endeavor that requires careful planning and preparation. A business plan is a critical tool that can help you to organize your thoughts, set goals, and create a roadmap for your practice's success. In this article, we discuss steps on how to establish a business plan for your holistic practice and provide some tips for creating a successful strategy.

Practice Management

CMS Announces Increase in 2023 in Organizations and Beneficiaries Benefiting from Coordinated Care in Accountable Care Relationships:Recently, the Centers for Medicare & Medicaid Services (CMS) announced that three innovative accountable care initiatives will grow and provide higher quality care to more than 13.2 million people with Medicare in 2023. More than 700,000 healthcare providers and organizations will participate in at least one of the three initiatives – the Medicare Shared Savings Program and two CMS Innovation Center accountable care model tests. This growth furthers achieving CMS's goal of having all people with Traditional Medicare in an accountable care relationship with their healthcare provider by 2030.

Practice Management

Investigation of Hospitals Hiding Prices from Patients:The Federal Hospital Price Transparency Rule helps Americans know the cost of a hospital item or service before receiving it. Compliance is mandatory. The regulation aims to improve the affordability of hospital care by promoting price competition. However, a low compliance level among hospitals would compromise the operational effectiveness of this regulation.

Practice Management

Top 5 Ways Medical Practices Can Combat Inflation:Inflation is affecting many businesses, but medical practices tend to see the brunt of its effects because of the way payment structures are dictated by insurance payers. Even more worrisome, practices have had to increase wages significantly and the current job market tends to favor employees.

Practice Management

Burnout: A Threat to Our Healthcare System?:The coronavirus disease 2019 (COVID-19) pandemic has generated a substantial increase in the workload of healthcare professionals, leading to physical and mental distress among professionals, resulting in an increase in burnout.

Practice Management

Digital Collaboration Maximizes Efficiency and Reduces Congestion in the Healthcare Ecosystem:CBS reports that excessive financial waste in our healthcare system ranges from $760 billion to $935 billion per year - that's more than the total for annual federal defense spending. The largest portion of this excess is administrative activities; these tasks required of physicians, their staff, and nurses are complex and devour so much time that they waste hundreds of billions of dollars each year.

Practice Management

Expanded Authorization for Non-Physician Providers:The opportunities for non-physician providers (NPP) in radiology practices continue to expand. Recently, the American College of Radiology (ACR) revised its CT and MRI facility accreditation criteria to allow NPPs to be able to directly supervise contrast administration.

Practice Management

12 Tips to Grow Your Medical Practice in 2023:If you are a private practice owner, you may feel it is difficult to attract new patients. By setting a plan and sticking to it, you can set yourself up for success in 2023. Medical practice management requires the collaborative efforts of all team members.

Practice Management

Value-Based Healthcare and Evidence-Based Treatment Rank Highest:Recently, we conducted a new survey on our LinkedIn asking respondents the question, "What do you see as the most important factor that technology solutions can solve to fuel better and more efficient patient outcomes in 2023?"

Practice Management

To Benchmark or Not to Benchmark: That Is the Question:Curiosity is both a blessing and a curse. Wanting to know how you compare to other practices can be so enticing that we are sometimes willing to accept assumptions that are not always supported by the evidence.

Practice Management

Demonstrating the Value of Patient Access in Challenging Times:It's no secret: Most healthcare organizations today are facing significant financial challenges - and there isn't a single culprit to blame. Instead, it's a perfect storm of circumstances fueled by an uncertain economy, workforce shortages, ongoing COVID-19 recovery, and public health issues such as RSV and the impact of delayed care.

Practice Management

The Medicare Advantage Bill Was Crafted in Response to Complaints:U.S. Senators Maggie Hassan, D-N.H., and Dr. Roger Marshall, R-Kansas, have introduced the bipartisan Medicare & You Handbook Improvement Act, which is meant to ensure that when seniors assess their Medicare coverage options, they have the necessary information they need on health plan choices and supplemental insurance.

Practice Management

The Advance Beneficiary Notice or ABN:An Advance Beneficiary Notice (ABN) is one of the most abused forms at a patient visit. When we, as a patient, seek medical care, that medical care is a covered or a non-covered service. If it is a covered service, that means that the service is payable by our health benefit plans.

Practice Management

The U.S. Government and Cooperation Credit in Relation to the False Claims Act and the Federal Anti-Kickback Statute:Those familiar with the healthcare industry have no doubt learned that the U.S. Department of Health and Human Services Office of the Inspector General (HHS-OIG) and the U.S. Department of Justice (DOJ) have identified both the False Claims Act (FCA) and the Anti-Kickback Statute (AKS) as laws critical to thwarting fraud, waste, and abuse. Often, these two laws come together in a FCA case.

Practice Management

Problems Addressed Regardless of the Place or Type of Service:I can't remember if I've recently covered this topic, so one of us (or maybe both of us) may have deja vu today. We're still getting inundated with questions about Problems Addressed regardless of the place or type of service, so whether I've already covered this topic or not, it bears addressing it again.

Practice Management

What Is a Patient Care Policy? (+ How to Write One):If you've never heard of a patient care policy before, then you might ask yourself if your medical practice needs another piece of business writing. The answer is yes; it's a good rule of thumb for your practice to have such a policy.

Practice Management

DME Billing Coverage Limitations and Exclusions :Durable medical equipment (DME) billing is an essential aspect of revenue cycle management in the healthcare industry. As the industry evolves, DME has grown in importance and now serves millions of patients. However, managing the billing processes and reimbursements associated with DME can be time consuming and labor intensive.

Practice Management

How to Reduce Patient Collections in a Medical Office:Putting on the dreaded collections hat is a necessary evil that every medical office can relate to. You can run a tight ship, doing your very best to collect payments at the time of service, but because of the complexities of medical billing and emergent situations, there will always be times when collecting every patient's payment is an impossibility.

Practice Management

What Are SOAP Notes? (And Why They’re Important for Insurance Billing):Healthcare documentation is a critical component for your holistic practice, both in terms of delivering great care to your patients and for insurance billing purposes-not to mention the importance of having some form of documentation in the event of a legal situation.

Practice Management

Let's Talk about Weed (As in the Doctor):Early September marked my 33rd year on the administrative side of healthcare. This followed my 56th birthday in April when I officially entered the realm of "pushing 60."

Practice Management

DENIED! CO 22-This care may be covered by another payer, per coordination of benefits?!?:Coordination of benefits can be described as when two or more insurance plans work together to determine the order of coverage liability. This coordination between plans exists to avoid duplicate payment, which could result in a provider receiving payment in excess of the services provided and the total amount billed.

Practice Management

A Cautionary Tale about Personal Injury Protection, Health Insurance...and Lawsuits:Medical providers who treat individuals for injuries sustained in motor vehicle accidents (MVAs) are frequently tasked with identifying the proper insurance carrier that is responsible for payment.

Practice Management

Medicare Patients and Stark Law: What You Need to Know:If your medical practice treats patients covered by Medicare, then you already know that there are countless regulations you need to closely adhere to in order to avoid any issues with the government.

Practice Management

Implications of the Federal Trade Commission's Report on Artificial Intelligence In the Healthcare Sector:No doubt, most people have heard of the phrase, "You are what you eat," which means that what we eat and our lifestyle choices impact our health and well-being.

Practice Management

Patients Charged Expensive Out-of-Pocket Fees as Doctors Stop Bulk Billing:Perth mother Jayme Lees has been bulk billed by her General Practitioner (GP) for the past six years, but when she took her newborn son for a check-up in June, she was hit with a hefty, unexpected fee.

Practice Management

Telehealth Here to Stay, But Technology Needs to Catch Up:Patient care in a post-COVID-19 world is significantly different for providers who are embracing virtual care options, such as telehealth and asynchronous texting.